- Email: [email protected]
Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors
Original Research
ajog.org
EDUCATION
Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors Eduardo Hariton, MD, MBA; Benjamin Matthews, MD; Abigail Burns, MD, MSW; Chitra Akileswaran, MD, MBA; Lori R. Berkowitz, MD
BACKGROUND: The health and economic benefits of paid parental leave have been well-documented. In 2016, the American College of Obstetricians and Gynecologists released a policy statement about recommended parental leave for trainees; however, data on adoption of said guidelines are nonexistent, and published data on parental leave policies in obstetrics-gynecology are outdated. The objective of our study was to understand existing parental leave policies in obstetrics-gynecology training programs and to evaluate program director opinions on these policies and on parenting in residency. OBJECTIVE: A Web-based survey regarding parental leave policies and coverage practices was sent to all program directors of accredited US obstetrics-gynecology residency programs. STUDY DESIGN: Cross-sectional Web-based survey. RESULTS: Sixty-five percent (163/250) of program directors completed the survey. Most program directors (71%) were either not aware of or not familiar with the recommendations of the American College of Obstetricians and Gynecologists 2016 policy statement on parental leave. Nearly all responding programs (98%) had arranged parental leave for 1 residents in the past 5 years. Formal leave policies for childbearing and
T
he decision to become a parent during medical training is complex, because trainees balance professional and personal priorities in the context of perceived stigma against parenting during training.1 Still, for many trainees, the benefit of becoming a parent outweighs any anticipated disadvantage: 85% of pregnancies among young female physicians are planned.2 The law protects pregnant workers from discrimination, but parental leave policies go further to create a supportive environment for trainees who decide to become parents during residency
Cite this article as: Hariton Eduardo, Matthews Benjamin, Burns Abigail, et al. Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors. Am J Obstet Gynecol 2018;:. 0002-9378/$36.00 ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.2018.04.017
nonchildbearing parents exist at 83% and 55% of programs, respectively. Program directors reported that, on average, programs offer shorter parental leaves than program directors think trainees should receive. Coverage for residents on leave is most often provided by co-residents (98.7%), usually without compensation or schedule rearrangement to reduce work hours at another time (45.4%). Most program directors (82.8%) believed that becoming a parent negatively affected resident performance, and approximately one-half of the program directors believed that having a child in residency decreased well-being (50.9%), although 19.0% believed that it increased resident well-being. Qualitative responses were mixed and highlighted the complex challenges and competing priorities related to parental leave. CONCLUSION: Most residency programs are not aligned with the American College of Obstetricians and Gynecologists recommendations on paid parental leave in residency. Complex issues regarding conflicting policies, burden to covering co-residents, and impaired training were raised. Key words: parental leave, residency
training.3 Parental leave is associated with improved maternal and infant health as well as enhanced mental health and increased employee productivity.4-6 Across numerous specialties, most training programs have formalized leave policies for childbearing parents, commonly referred to as “maternity leave.”7-11 Policies for nonchildbearing parents (typically “paternity leave” or “partner leave”) are less common and typically less robust.7,10 In Obstetrics and Gynecology specifically, published data about parental leave policies are outdated; the most recent survey of US Obstetrics and Gynecology programs occurred >15 years ago.7 Since then, major changes have occurred in graduate medical education generally and in Obstetrics and Gynecology specifically. These changes, such as national implementation and updates of work-hours restrictions, growing awareness of physician burnout, and enhanced options for LGBTQ
parenthood, have likely altered parental leave needs and their implementation; however, the effect of these changes has not been studied.12-14 Specialty-specific policy changes include a July 2016 statement from the American College of Obstetricians & Gynecologists (ACOG) endorsing 6 weeks of paid leave for all new parents, childbearing or not, distinguished from vacation and sick time, and without requirements to make up missed call shifts.15 Our study seeks to understand current parental leave policies in Obstetrics and Gynecology training programs for comparison with professional society guidelines and past studies and to evaluate program director opinions on these policies and on parenting in residency as a whole.7,15
Methods A questionnaire was designed by the authors that was based on a previous validated survey tool used in general
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e1
Original Research
EDUCATION
AJOG at a Glance Why was this study conducted? The study was conducted to understand parental leave practices and the perceptions of program directors toward parental leave in Obstetrics-Gynecology. Key Findings Most programs do not align with the American College of Obstetricians and Gynecologists recommendations on paid parental leave in residency. Perceived constraints lead program directors to offer shorter leaves than they find trainees should receive. What does this add to what is known? This is the first study in 16 years to evaluate parental leave policies in ObstetricsGynecology. We describe program directors’ perceived barriers to offering parental leave that meets American College of Obstetricians and Gynecologists minimum guidelines, as well as solutions to overcome these.
surgery to evaluate parental leave policies and program director perceptions of these policies.10 Our questions were then compared with those used by Davis et al7 to be able to compare the evolution of parental leave policies specifically in Obstetrics and Gynecology. There were 33 total items: 23 multiple-choice questions about parental leave policies, coverage practices, the effects of becoming a parent on training, wellbeing, breastfeeding, and awareness of ACOG’s policy statement; 9 demographics questions; and 1 free response section to provide additional comments. All questions were optional. After being adapted for Obstetrics and Gynecology respondents, the survey was piloted with academic faculty who interact with residents on a regular basis at our institution. Feedback was collected, and minor changes that did not alter the questions’ structure were incorporated for content and clarity. The survey was created for email distribution and data collection via SurveyMonkey (SurveyMonkey, Inc, Palo Alto, CA). An email listing of all program directors at Accreditation Council for Graduate Medical Educationeaccredited Obstetrics and Gynecology residency programs was created with the use of information available on the ACOG and Association of Professors of Gynecology and Obstetrics Web sites.16,17 The survey was distributed via email to 250 program directors on April 3, 2017, and 2 reminders were sent,
each 2 weeks apart. Data collection closed on May 19, 2017. After closing, quantitative data were downloaded and analyzed with the use of descriptive statistics in Microsoft Excel 2008 (Microsoft Corporation, Redmond, WA). Qualitative text responses were analyzed by content analysis. Free responses answers were analyzed by this method, and consensus codes were reached by 2 of the authors through an iterative process with preliminary and secondary coding. All comments and themes were reviewed by a third reviewer and were then discussed by all 3 authors until consensus was reached. This survey study was reviewed and deemed exempt by the Partners HealthCare Institutional Review Board.
Results A total of 163 of 250 (65.2%) program directors completed the survey. Ninetyone percent (n¼148) of respondents completed demographic and program statistic questions (Table 1). Fifty-seven percent were from university programs; 30.6% were from community programs, and 3.1% were from military programs. All Council on Resident Education in Obstetrics and Gynecology regions were represented, with Region 2 having the most responses (24.5%). Approximately equal numbers of respondents had served in their leadership positions for <3 years (28.8%), 3e5 years (26.9%), and 6 years (31.9%). Sixty-four percent of respondents were female,
1.e2 American Journal of Obstetrics & Gynecology MONTH 2018
ajog.org and 66.8% of respondents had children, with 35.6% of them having had children during medical training. Most program directors (71%) were either not aware of the ACOG 2016 policy statement (44.7%) or were not familiar with its recommendations related to parental leave (26.3%). Nearly all responding programs (98%) had arranged parental leave for 1 residents in the past 5 years. Formal leave policies for childbearing parents exist at 82.8% of programs (Table 2). Fifty-five percent of respondents reported that their program had a formal leave policy for nonchildbearing parents; 17% of the respondents reported that they were unsure, and 26% of the respondents reported that they have no such policy. Forty-two percent of them reported that their leave policies are included in resident contracts. Program directors reported that, on average, programs offer shorter parental leaves than program directors think trainees should receive; 44.1% of childbearing and 68.7% of nonchildbearing residents receive shorter leaves than their program directors believe they should, respectively. A majority of program directors (72.4%; n¼118) believed that a childbearing resident should be able to take >6 weeks of leave. Most commonly, however, childbearing residents take 4e6 weeks (49.0%). There was less agreement regarding how much time nonchildbearing parents should be granted, ranging from none (3.1%) to >8 weeks (7.4%), with 2e4 weeks being the most common response (30.6%). In practice, nonchildbearing parents most commonly take 1 day to 2 weeks (61.9%), with 11.0% of program directors reporting that nonchildbearing residents in their programs take no time out of training (Figure). No significant differences were seen after comparing small (<6 residents) to large (>7 residents) programs. Coverage for residents on leave is provided by co-residents at 98.7% of programs. In a minority of programs, fellows and/or attendings may assist with coverage needs (19.6%), and only 3.6% of programs hire temporary staff.
ajog.org
EDUCATION
TABLE 1
Program director demographics Variable
N (%)
National, n (%)
105 (71.4)
Approximately 58%
42 (28.6)
Approximately 42%
Gender (n-147) Female Male Another gender identity
0
Years in residency leadership (n¼143) <3
47 (32.9)
N/A
3e5
44 (30.8)
N/A
6e10
34 (23.8)
N/A
>10
18 (12.6)
N/A
0e5
31 (21.7)
N/A
Years after training (n¼143) 6e10
23 (16.1)
N/A
11e15
24 (16.8)
N/A
16e20
27 (18.9)
N/A
21e25
20 (14.0)
N/A
26
18 (12.6)
N/A
50 (33.8)
131 (51.2)
Type of program (n¼148) Community Military University
5 (3.4)
7 (2.7)
93 (62.8)
118 (46.1)
1e3
38 (14.8)
15%
4e9
132 (90.4)
75%
>9
4 (2.7)
10%
0e20
2 (1.4)
N/A
21e40
0
N/A
Program size (n¼146), residents/y
Resident gender (n-147), % female
41e60
4 (2.7)
N/A
61e80
67 (45.6)
N/A
81e100
74 (50.3)
N/A
Region 1
21 (14.2)
52 (20.3)
Region 2
40 (27.0)
60 (23.4)
Region 3
28 (18.9)
42 (16.4)
Region 4
36 (24.3)
63 (24.6)
Region 5
23 (15.5)
39 (15.2)
Program region (n¼148)
N/A, not available. Total, 153; 10 survey respondents completed no demographics information. The number varies within each category because not all respondents answered each question. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
Original Research
Resident coverage most often occurs without financial compensation or schedule rearrangement to reduce work hours at another time (45.4%). In 40.5% of programs, the resident on leave is expected to make up all missed call shifts; in 23.9% of programs, no make up work is required. Most program directors (82.8%) believed that becoming a parent negatively affected resident performance in some way. Limitation of scholarly activities was most cited (52.7%), with diminished timeliness (30.6%), less dedication to patient care (29.4%), and lower surgical volume (27.6%) after the leave. Of note, only 13.4% of program directors believed that becoming a parent resulted in diminished clinical skills. Approximately one-half of program directors believed that having a child in residency decreased well-being (50.9%); 19.0% believed that it increased resident well-being. The remaining directors were neutral or believed that the impact was mixed. Twelve program directors (7%) said they would advise against becoming a childbearing parent during residency. Last, most program directors (85.8%) believed new parenting is more challenging for female residents than for male residents, with 44.7% stating that it is more challenging for childbearing and nonchildbearing female residents alike; 41.7% of them stated that the greater challenge applied to childbearing female residents only. Regarding qualitative responses, programs directors most often used the freeresponse section to explain the reason that the ideal parental leave policies are usually more comprehensive than what their programs offered residents. The themes that were identified can be found in Table 3. The most common themes that arose from our qualitative analysis were conflicting policies (35.0%), work hour or policy barriers (32.5%), burden to co-residents (27.5%), limited resources (17.5%), and impaired training (15.0%; Table 3). Other notable themes that were identified were program director desire for more support (25.0%),
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e3
Original Research
ajog.org
EDUCATION
call for policy changes at the national level (12.5%), and enhanced well-being of parents (10.0%).
TABLE 2
Program director responses Questions and answers
Percentage of replies
Comment
Before this survey, were you aware of the July 2016 American College of Obstetricians and Gynecologists Policy Statement on paid parental leave? Yes
28.8
Aware of it, but not of its recommendations
26.4
No
44.8
Does your program have a formal policy regarding childbearing parental leave (commonly referred to as “maternity leave”)? Yes
82.8
No
9.8
Unsure
6.7
Does your program have a formal policy regarding nonchildbearing parental leave (commonly “paternity” or “partner” leave)? Yes
55.2
No
26.4
Unsure
17.2
Where can your parental leave policies be accessed? (multiple response) Publicly accessible online
17.2
Available on a private, password-protected intranet
41.1
Included in employment contracts
41.7
Included in recruitment materials provided at residency interviews
17.2
Available on request
53.4
Who covers for residents in your program who take parental leave? (multiple response) Other residents
98.8
Fellows, attending physicians
19.6
Moonlighters, hired coverage
3.7
Coverage typically not necessary
11.0
If residents cover for co-residents on leave: Do residents receive additional financial compensation for coverage? Yes
1.2
No, but their schedule is rearranged so that they work fewer hours at another time
47.2
No, residents cover without additional financial compensation or schedule rearrangement
45.4
Not applicable/unsure
4.9
At your residency program, is there flexibility to allow some rotations or calls to go uncovered by residents? Yes
54.0
No
45.4
Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
1.e4 American Journal of Obstetrics & Gynecology MONTH 2018
(continued)
Our study shows that, although nearly all program directors who responded have extended parental leave to their trainees, only 83% and 55% of programs have formal leave policies for childbearing and nonchildbearing parents, respectively. Most residency programs offer shorter parental leave than program directors think they should and do not meet ACOG’s recommendations on paid parental leave in residency. Several barriers to offering improved leave policies were raised and included the perceived negative effect of parenting in residency and the burden to covering for coresidents. The health and economic benefits of paid parental leave have been wellstudied and include lower rates of infant mortality, improved health for mother and child, and improved worker morale and retention.4,18-20 In the context of a national dialogue that aims to support women in the workplace through practices that include paid parental leave, lactation support, and a more family-friendly work environment, ACOG published a policy statement in 2016. In this communication, ACOG recommends 6 weeks of paid parental leave for residents, separate from sick or vacation time, and that trainees are not required to make up missed calls.15 This study quantitatively and qualitatively examined Obstetrics and Gynecology program directors’ attitudes regarding parental leave policies and their perceived effects of parenting during Obstetrics and Gynecology residency. Nearly two-thirds of all US Obstetrics and Gynecology programs are represented in the responses, which demonstrate ongoing interest in this subject that has been studied minimally in recent years. Our study shows that most training programs in Obstetrics and Gynecology fall short of meeting these recommendations. Although the statement provides ideas about the types of policies that residency programs should
ajog.org
EDUCATION
Original Research
FIGURE
TABLE 2
Ideal vs actual parental leave
Program director responses (continued) Questions and answers
Percentage of replies
Are residents who take parental leave required to make up missed call shifts? Yes, all shifts
40.5
Yes, some shifts
34.4
No
23.9
Are residents required to use available sick or vacation time as part of their parental leave? Yes
67.5
No
31.3
This is a comparison of the length of parental leave that childbearing and nonchildbearing trainees should “ideally” take and “usually” take. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
How much do you think becoming a parent affects an ObstetricsGynecology resident’s well-being during training? Increases significantly
4.9
Increases somewhat
14.1
Neutral effect
27.6
Decreases somewhat
37.4
Decreases significantly
13.5
In what ways does becoming a parent most negatively affect resident performance? (multiple selection, maximum 3) Not applicable; no appreciable negative impact
14.1
Diminished clinical skills
13.5
Less dedication to patient care
29.4
Limitation of scholarly activities
52.8
Diminished timeliness
30.7
Lower surgical volume
27.6
Total, 163. Percentages do not total 100 for multiple response questions or because not every respondent answered every question. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
offer, it offers little in terms of guidelines to implement them. In practice, most programs do not have equal leave policies for nonchildbearing resident parents, and 75% of the programs require residents to make up all or some of the call shifts missed while on leave, directly contradicting 1 of the main tenets of the statement. Of note, 44% of program directors were not aware of this guidance, raising the need for better dissemination. Although a minority of program directors expressed disapproval toward the ACOG policy statement’s ideals, most expressed a desire to offer policies more aligned with the statement’s guidelines. For both childbearing and nonchildbearing parents, programs offer less
leave time than directors think resident parents ought to have. In both quantitative and qualitative responses, a key issue cited is how American Board of Obstetrics and Gynecology guidelines constrain flexibility for program directors to allow for a 6-week minimum standard for parental leave. Specifically, American Board of Obstetrics and Gynecology delineates the maximum number of clinical weeks a trainee can miss without having to make up time. With the ongoing paradigm shift towards competency-based training, timebased residency requirements could be relaxed in to allow for compliance with the ACOG statement. Additionally, because parental leave policies are often not included in employment contracts
or, in one-half of cases, not even available upon request, 1 straightforward way to increase compliance with the statement is to increase prospective residents’ access to policy details. This access may help residents make better informed decisions when selecting residency programs and during family planning. Furthermore, it may also stimulate discussion and help the postgraduate medical community determine how best to enact such leave policies. In the 17 years since Davis et al7 published their study, there has been minimal change in the number of programs that offer parental leave in Obstetrics and Gynecology. In 2001, 80% and 69% of programs reported having formal childbearing and nonchildbearing leave policies, respectively.7 In our study, the numbers have changed only slightly, at 83% and 55%, respectively. Furthermore, in 2001, 77% of residents on parental leave were covered by other residents, and 37% of programs had the ability to leave shifts uncovered. Today, residents cover the shifts in 98.8% of the programs, despite 54% of programs reporting the ability to let some rotations or calls go uncovered. This suggests that, despite the implementation of work hour restrictions in the interim, residents have faced an increase in the coverage burden for residents on leave, which is an often cited concern. This issue is of paramount importance if parental leave policies are to succeed, because the small size of
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e5
Original Research
ajog.org
EDUCATION
TABLE 3
Themes identified in open-ended responses by domain queried Answers from program directors (n¼40) Conflicting policies at the national level (n¼14; 35.0%)
“I think it’s positive that ACOG and ACGME are more supportive in position statements and at meetings of residents and fellows becoming parents. However, we struggle.the requirements are complicated..so when residents are planning time off they are often confused by the different regulations and requirements of these different agencies.” “There is a very important distinction between rights and responsibilities as an employee and those as a trainee. ABOG requirements on trainees are the limiting factor in granting time off, not employee leave policies.”
Work hour/policy barriers (n¼13; 32.5%)
“The coverage schemes get stretched when one resident is away and other residents may become resentful so we ask people to make up their call. This makes it so that when residents come back from leave, they have a much more rigorous call schedule as they make up shifts, which is also not ideal as they have an infant at home.” “Having one or more residents out disrupts the training and work-load for all other remaining residents, especially in small programs, such as ours.”
Coverage burden to co-residents (n¼11; 27.5%)
“There are negative effects on the well-being of the residents that are left to cover for childbearing and nonchildbearing residents taking extended leave.” “Allowing this extremely liberal approach will create a logistical nightmare, and a truly unfair environment with regard to the male physicians (still at 20%), as well as those female physicians who defer childbearing.”
Program director desire for more support (n¼10; 25.0%)
“If Obstetrics and Gynecology isn’t family-friendly, then there is no hope for the other specialties.” “We unfortunately live in a world where we don’t practice what we preach. We advocate for our patients to get the time they need to start families, but our residents are left behind with suboptimal parental leave policies and minimal support.” “It is hard to believe that in the field of Obstetrics and Gynecology, policies that are more supportive of residents that have children during residency do not exist. Even worse that the view of the program and even other residents is that maternity leave is viewed as vacation time that will have to be paid in one way or the other.”
Limited resources (n¼7; 17.5%)
“All people in the United States need more family leave, period. Your problem is who will pay for it? We cannot afford to let everyone extend residency, as there is no money to do so...You either sacrifice for 4 years and wait or you find money to fund yourself to extend. This is not a matter of what is right or wrong- it’s a matter of finding the money to support.”
Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
some training programs, financial constraints, training requirements, and work-hour restrictions complicate
(continued)
coverage schemes. Larger programs may be able to use “swing” residents to cover new parents on leave or to let some
1.e6 American Journal of Obstetrics & Gynecology MONTH 2018
services go uncovered. This may allow some programs not to require new parents to make up missed call shifts. A small minority of programs reported hiring temporary staff to cover residents on leave, which is a practice that is common in other workplace settings that may help offer a more sustainable solution; however, funding this option may be prohibitive for some programs. In comparison with a 2016 study of General Surgery program directors, more Obstetrics and Gynecology directors in this study believed that parenting negatively affected resident performance (82.8% vs 61%) and were also more likely to say that new parenthood during residency negatively impacted well-being (51% vs 32%).10 This is consistent with respondents who cited that new parenthood affects female residents more than male residents and Obstetrics and Gynecology’s greater proportion of female trainees. Because medicine continues to embrace women in the workforce, we must adapt medical training to support this diversified workforce. Similar to when workhour restrictions were implemented, some stakeholders have expressed concern that more generous parental leave policies would come at the cost of graduate preparation. However, a study of Obstetrics and Gynecology residents showed that surgical volume was not affected by parental status.21 Although further studies may help clarify the perceived negative effect of parenthood on trainees, it is unlikely that residents will cease to build families in residency. Hence, we must focus on creating a work environment that can support resident parents, childbearing or not, as they complete their medical training. Studies show an increased risk of late pregnancy complication and pregnant trainees reported lack of support from fellow residents and their departments as the most stressful aspect of their pregnancy.22 This perceived lack of support, in the setting of inadequate parental leave policies, can lead residents to leave their programs before completing training and may be contributing to the 4.2% attrition rate that was seen in a recent study of
ajog.org
EDUCATION
TABLE 3
Themes identified in open-ended responses by domain queried (continued) Answers from program directors (n¼40) “I do not have the resources, both administrative and from the national organizations, to support parents to the degree that I believe we should. My residents must make up all calls because I don’t have funding to pay a moonlighter. This makes it so that they are working harder than their colleagues when they are pregnant, and then harder again after they come back from maternity/ paternity leave, both suboptimal in my opinion.” Impaired training of residents with “.no should someone get out of call because they had a children (n¼6; 15%) baby. You make up that call to your fellow residents. Some people need surgery or break bones or need to take care of sick parents or children- it’s all the same.” “Becoming a parent certainly takes away any extra time you would other spend at the hospital providing extra clinical care. Also, there is much less time for research and scholarly activities.” “Residents should be focused on residency during training. Having children, whether they are the childbearing parent or not, is a distraction and the best clinicians are focused on medicine. It also creates great financial pressure. I recommend my residents not start families while in residency because the burden is quite high.” Call for policy changes at the national level (n¼5; 12.5%)
“I hope that our national organizations, which are great at supporting mothers to be and mothers, extend that to their own trainees and that we advocate to provide better support to those who choose to build their families in residency.” “I think it is critical that we therefore adjust our expectations for residency to include parental leave and breastfeeding and accommodate accordingly.”
Enhances well-being of residents with children (n¼4; 10.0%)
“Having a child has a wonderful positive impact too.” “Being a parent increases an obstetrician/gynecologist’s ability to empathize with their patients and allows our trainees to live fulfilling personal lives outside the hospital.”
ABOG, American Board of Obstetrics and Gynecology; ACGME, Accreditation Council for Graduate Medical Education; ACOG, American College of Obstetricians and Gynecologists. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
Obstetrics and Gynecology trainees.23 Failing to improve parental leave policies further poses a significant risk to the specialty, because highly qualified candidates may choose training programs or specialties that are more supportive of parent trainees. Given the expected shortfall of 8880 obstetricians and gynecologists in the workforce by 2020, it is especially important to establish competitive career paths with adequate work-life balance to our trainees as well as our practicing physicians.24
Major strengths of our study are our response rate (65.2%) and the dual quantitative and qualitative nature of our results. Our respondents are well distributed across Council on Resident Education in Obstetrics and Gynecology regions and program types, although we acknowledge that, with a higher response rate, our results would be more easily generalizable. Limitations to our study include possible response bias and limited demographic information for respondents, because not all directors
Original Research
provided this information. Response bias may account for the fact that 71.4% of respondents were female; only 58% of directors nationwide are; this may suggest a greater interest in the subject matter among female directors. Furthermore, our survey was validated previously in general surgery. After being adapted for Obstetrics and Gynecology respondents, it was tested with academic faculty only, so there may be survey bias in that our target population also included nonacademic program directors. Residency program directors face the challenges of supporting residents who choose to start families and protecting covering co-residents from becoming overburdened, all while ensuring adequate clinical training for all. Programs should, at a minimum, establish and make program policies available to current and future trainees. Although time-based residency training guidelines currently limit flexibility, a trend towards competency-based training and evaluation may allow for more creative solutions for program directors who seek to offer more robust parental leave policies and closer alignment with ACOG’s parental policy guidelines. Increasing the availability of affordable on-site child care and developing part-time training options may further help support new trainee parents.25 Ultimately, solutions will need to be tailored individually to a program’s structure and coverage needs. Although there are clear challenges in expanding paid parental leave coverage for trainees, there is also a significant cost of inaction. We hope our study serves to inform and catalyze more uniformity in parental leave for Obstetrics and Gynecology trainees nationwide. n Acknowledgments Britt J. Sandler (University of Washington) and Peter S. Yoo (Yale University) for their contributions to the creation of our survey tool.
References 1. Mundschenk M, Krauss EM, Poppler LH, et al. Resident perceptions on pregnancy during training: 2008 to 2015. Am J Surg 2016;212: 649-59. 2. Stentz NC, Griffith KA, Perkins E, DeCastro Jones R, Jagsi R. Fertility and childbearing
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e7
Original Research
EDUCATION
among American female physicians. J Womens Health 2016;25:1059-65. 3. US Equal Employment Opportunity Commission. The Pregnancy Discrimination Act of 1978. Available at: https://www.eeoc.gov/laws/ statues/pregnancy.cfm. Accessed November 16, 2017. 4. Rossin M. The effects of maternity leave on children’s birth and infant health outcomes in the United States. J Health Econ 2011;30:221-39. 5. Avendano M, Berkman LF, Brugiavini A, Pasini G. The long-run effect of maternity leave benefits on mental health: evidence from European countries. Soc Sci Med 2015;132:45-53. 6. Baughman R, DiNardi D, Holtz-Eakin D. Productivity and wage effects of “family-friendly” fringe benefits. Int J Manpow 2003;24:247-59. 7. Davis JL, Baillie S, Hodgson CS, Vontver L, Platt LD. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol 2001;98:1093-8. 8. McPhillips HA, Burke AE, Sheppard K, Pallant A, Stapleton FB, Stanton B. Toward creating family-friendly work environments in pediatrics: baseline data from pediatrics department chairs and pediatrics program directors. Pediatrics 2007;119:596-602. 9. Weiss J, Teuscher D. What provisions do orthopaedic programs make for maternity, paternity, and adoption leave? Clin Orthop 2016;474:1945-9. 10. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. J Am Coll Surg 2016;222:1090-6. 11. Garza RM, Weston JS, Furnas HJ. Pregnancy and the plastic surgery resident. Plast Reconstr Surg 2017;139:245-52. 12. Accreditation Council for Graduate Medical Education (ACGME) Task Force on Quality Care
and Professionalism. The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development. Available at: http://www.acgme.org/Portals/ 0/PDFs/jgme-monograph[1].pdf. Accessed November 16, 2017. 13. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. 14. National LGBT Health Education Center. Pathways to Parenthood for LGBT People. Available at: http://www.lgbthealtheducation. org/wp-content/uploads/Pathways-to-Parenthood -for-LGBT-People.pdf. Accessed November 16, 2017. 15. The American College of Obstetricians and Gynecologists. Statement of Policy: Paid Parental Leave. July 2016. Available at: https://www.acog.org/media/Statements-ofPolicy/Public/92ParentalLeaveJuly16.pdf?dmc ¼1&ts¼20161112T1513227627. Accessed November 16, 2017. 16. Residency Program Directory by Region. Available at: http://www.acog.org/AboutACOG/ACOG-Departments/CREOG/CREOGSearch/Residency-Program-Directory-by-Regions. Accessed January 15, 2016. 17. Residency Directory Search. Available at: https://www.apgo.org/component/residence directory. Accessed January 15, 2016. 18. Ruhm CJ. Parental leave and child health. J Health Econ 2000;19:931-60. 19. Berger LM, Hill J, Waldfogel J. Maternity leave, early maternal employment and child health and development in the US. Econ J 2005;115:F29-47. 20. Gault B, Hartmann H, Hegewisch A, Mili J, Reichlin L. Paid parental leave in the United States: what the data tell us about access, usage, and economic and health benefits. Washington, DC: Institute for Women’s Policy Research. 2014. Available
1.e8 American Journal of Obstetrics & Gynecology MONTH 2018
ajog.org at: http://www.iwpr.org/publications/pubs/ paid-parental-leave-in-the-united-states-what-thedata-tell-us-about-access-usage-and-economicand-health-benefits/. Accessed August 27, 2017. 21. Lashbrook DL, Frazier LM, Horbelt DV, Stembridge TW, Rall MJ. Pregnancy during obstetrics and Gynecology residency: effect on surgical experience. Am J Obstet Gynecol 2003;189:662-5. 22. Finch SJ. Pregnancy during residency: a literature review. Acad Med 2003;78:418-28. 23. Waldman JD, Kelly F, Arora S, Smith HL. The shocking cost of turnover in health care. Health Care Manage Rev 2004;29:2-7. 24. Rayburn W. The Obstetrician-Gynecologist Workforce in the United States; Facts, Figures, and Implications. Washington, DC: American College of Obstetricians and Gynecologists; 2011. 25. Jagsi R, Tarbell NJ, Weinstein DF. Becoming a doctor, starting a family — leaves of absence from graduate medical education. N Engl J Med 2007;357:1889-91.
Author and article information From the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (Drs Hariton, Burns, and Berkowitz); the Department of Obstetrics, Gynecology and Reproductive Biology, Brigham & Women’s Hospital, Harvard Medical School (Drs Hariton and Burns); the Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine (Dr Matthews); and the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center (Dr Akileswaran), Boston, MA. Received Feb. 7, 2018; revised April 9, 2018; accepted April 10, 2018. The authors report no conflict of interest. Corresponding author: Eduardo Hariton, MD, MBA. [email protected]
ajog.org
EDUCATION
Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors Eduardo Hariton, MD, MBA; Benjamin Matthews, MD; Abigail Burns, MD, MSW; Chitra Akileswaran, MD, MBA; Lori R. Berkowitz, MD
BACKGROUND: The health and economic benefits of paid parental leave have been well-documented. In 2016, the American College of Obstetricians and Gynecologists released a policy statement about recommended parental leave for trainees; however, data on adoption of said guidelines are nonexistent, and published data on parental leave policies in obstetrics-gynecology are outdated. The objective of our study was to understand existing parental leave policies in obstetrics-gynecology training programs and to evaluate program director opinions on these policies and on parenting in residency. OBJECTIVE: A Web-based survey regarding parental leave policies and coverage practices was sent to all program directors of accredited US obstetrics-gynecology residency programs. STUDY DESIGN: Cross-sectional Web-based survey. RESULTS: Sixty-five percent (163/250) of program directors completed the survey. Most program directors (71%) were either not aware of or not familiar with the recommendations of the American College of Obstetricians and Gynecologists 2016 policy statement on parental leave. Nearly all responding programs (98%) had arranged parental leave for 1 residents in the past 5 years. Formal leave policies for childbearing and
T
he decision to become a parent during medical training is complex, because trainees balance professional and personal priorities in the context of perceived stigma against parenting during training.1 Still, for many trainees, the benefit of becoming a parent outweighs any anticipated disadvantage: 85% of pregnancies among young female physicians are planned.2 The law protects pregnant workers from discrimination, but parental leave policies go further to create a supportive environment for trainees who decide to become parents during residency
Cite this article as: Hariton Eduardo, Matthews Benjamin, Burns Abigail, et al. Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors. Am J Obstet Gynecol 2018;:. 0002-9378/$36.00 ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.2018.04.017
nonchildbearing parents exist at 83% and 55% of programs, respectively. Program directors reported that, on average, programs offer shorter parental leaves than program directors think trainees should receive. Coverage for residents on leave is most often provided by co-residents (98.7%), usually without compensation or schedule rearrangement to reduce work hours at another time (45.4%). Most program directors (82.8%) believed that becoming a parent negatively affected resident performance, and approximately one-half of the program directors believed that having a child in residency decreased well-being (50.9%), although 19.0% believed that it increased resident well-being. Qualitative responses were mixed and highlighted the complex challenges and competing priorities related to parental leave. CONCLUSION: Most residency programs are not aligned with the American College of Obstetricians and Gynecologists recommendations on paid parental leave in residency. Complex issues regarding conflicting policies, burden to covering co-residents, and impaired training were raised. Key words: parental leave, residency
training.3 Parental leave is associated with improved maternal and infant health as well as enhanced mental health and increased employee productivity.4-6 Across numerous specialties, most training programs have formalized leave policies for childbearing parents, commonly referred to as “maternity leave.”7-11 Policies for nonchildbearing parents (typically “paternity leave” or “partner leave”) are less common and typically less robust.7,10 In Obstetrics and Gynecology specifically, published data about parental leave policies are outdated; the most recent survey of US Obstetrics and Gynecology programs occurred >15 years ago.7 Since then, major changes have occurred in graduate medical education generally and in Obstetrics and Gynecology specifically. These changes, such as national implementation and updates of work-hours restrictions, growing awareness of physician burnout, and enhanced options for LGBTQ
parenthood, have likely altered parental leave needs and their implementation; however, the effect of these changes has not been studied.12-14 Specialty-specific policy changes include a July 2016 statement from the American College of Obstetricians & Gynecologists (ACOG) endorsing 6 weeks of paid leave for all new parents, childbearing or not, distinguished from vacation and sick time, and without requirements to make up missed call shifts.15 Our study seeks to understand current parental leave policies in Obstetrics and Gynecology training programs for comparison with professional society guidelines and past studies and to evaluate program director opinions on these policies and on parenting in residency as a whole.7,15
Methods A questionnaire was designed by the authors that was based on a previous validated survey tool used in general
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e1
Original Research
EDUCATION
AJOG at a Glance Why was this study conducted? The study was conducted to understand parental leave practices and the perceptions of program directors toward parental leave in Obstetrics-Gynecology. Key Findings Most programs do not align with the American College of Obstetricians and Gynecologists recommendations on paid parental leave in residency. Perceived constraints lead program directors to offer shorter leaves than they find trainees should receive. What does this add to what is known? This is the first study in 16 years to evaluate parental leave policies in ObstetricsGynecology. We describe program directors’ perceived barriers to offering parental leave that meets American College of Obstetricians and Gynecologists minimum guidelines, as well as solutions to overcome these.
surgery to evaluate parental leave policies and program director perceptions of these policies.10 Our questions were then compared with those used by Davis et al7 to be able to compare the evolution of parental leave policies specifically in Obstetrics and Gynecology. There were 33 total items: 23 multiple-choice questions about parental leave policies, coverage practices, the effects of becoming a parent on training, wellbeing, breastfeeding, and awareness of ACOG’s policy statement; 9 demographics questions; and 1 free response section to provide additional comments. All questions were optional. After being adapted for Obstetrics and Gynecology respondents, the survey was piloted with academic faculty who interact with residents on a regular basis at our institution. Feedback was collected, and minor changes that did not alter the questions’ structure were incorporated for content and clarity. The survey was created for email distribution and data collection via SurveyMonkey (SurveyMonkey, Inc, Palo Alto, CA). An email listing of all program directors at Accreditation Council for Graduate Medical Educationeaccredited Obstetrics and Gynecology residency programs was created with the use of information available on the ACOG and Association of Professors of Gynecology and Obstetrics Web sites.16,17 The survey was distributed via email to 250 program directors on April 3, 2017, and 2 reminders were sent,
each 2 weeks apart. Data collection closed on May 19, 2017. After closing, quantitative data were downloaded and analyzed with the use of descriptive statistics in Microsoft Excel 2008 (Microsoft Corporation, Redmond, WA). Qualitative text responses were analyzed by content analysis. Free responses answers were analyzed by this method, and consensus codes were reached by 2 of the authors through an iterative process with preliminary and secondary coding. All comments and themes were reviewed by a third reviewer and were then discussed by all 3 authors until consensus was reached. This survey study was reviewed and deemed exempt by the Partners HealthCare Institutional Review Board.
Results A total of 163 of 250 (65.2%) program directors completed the survey. Ninetyone percent (n¼148) of respondents completed demographic and program statistic questions (Table 1). Fifty-seven percent were from university programs; 30.6% were from community programs, and 3.1% were from military programs. All Council on Resident Education in Obstetrics and Gynecology regions were represented, with Region 2 having the most responses (24.5%). Approximately equal numbers of respondents had served in their leadership positions for <3 years (28.8%), 3e5 years (26.9%), and 6 years (31.9%). Sixty-four percent of respondents were female,
1.e2 American Journal of Obstetrics & Gynecology MONTH 2018
ajog.org and 66.8% of respondents had children, with 35.6% of them having had children during medical training. Most program directors (71%) were either not aware of the ACOG 2016 policy statement (44.7%) or were not familiar with its recommendations related to parental leave (26.3%). Nearly all responding programs (98%) had arranged parental leave for 1 residents in the past 5 years. Formal leave policies for childbearing parents exist at 82.8% of programs (Table 2). Fifty-five percent of respondents reported that their program had a formal leave policy for nonchildbearing parents; 17% of the respondents reported that they were unsure, and 26% of the respondents reported that they have no such policy. Forty-two percent of them reported that their leave policies are included in resident contracts. Program directors reported that, on average, programs offer shorter parental leaves than program directors think trainees should receive; 44.1% of childbearing and 68.7% of nonchildbearing residents receive shorter leaves than their program directors believe they should, respectively. A majority of program directors (72.4%; n¼118) believed that a childbearing resident should be able to take >6 weeks of leave. Most commonly, however, childbearing residents take 4e6 weeks (49.0%). There was less agreement regarding how much time nonchildbearing parents should be granted, ranging from none (3.1%) to >8 weeks (7.4%), with 2e4 weeks being the most common response (30.6%). In practice, nonchildbearing parents most commonly take 1 day to 2 weeks (61.9%), with 11.0% of program directors reporting that nonchildbearing residents in their programs take no time out of training (Figure). No significant differences were seen after comparing small (<6 residents) to large (>7 residents) programs. Coverage for residents on leave is provided by co-residents at 98.7% of programs. In a minority of programs, fellows and/or attendings may assist with coverage needs (19.6%), and only 3.6% of programs hire temporary staff.
ajog.org
EDUCATION
TABLE 1
Program director demographics Variable
N (%)
National, n (%)
105 (71.4)
Approximately 58%
42 (28.6)
Approximately 42%
Gender (n-147) Female Male Another gender identity
0
Years in residency leadership (n¼143) <3
47 (32.9)
N/A
3e5
44 (30.8)
N/A
6e10
34 (23.8)
N/A
>10
18 (12.6)
N/A
0e5
31 (21.7)
N/A
Years after training (n¼143) 6e10
23 (16.1)
N/A
11e15
24 (16.8)
N/A
16e20
27 (18.9)
N/A
21e25
20 (14.0)
N/A
26
18 (12.6)
N/A
50 (33.8)
131 (51.2)
Type of program (n¼148) Community Military University
5 (3.4)
7 (2.7)
93 (62.8)
118 (46.1)
1e3
38 (14.8)
15%
4e9
132 (90.4)
75%
>9
4 (2.7)
10%
0e20
2 (1.4)
N/A
21e40
0
N/A
Program size (n¼146), residents/y
Resident gender (n-147), % female
41e60
4 (2.7)
N/A
61e80
67 (45.6)
N/A
81e100
74 (50.3)
N/A
Region 1
21 (14.2)
52 (20.3)
Region 2
40 (27.0)
60 (23.4)
Region 3
28 (18.9)
42 (16.4)
Region 4
36 (24.3)
63 (24.6)
Region 5
23 (15.5)
39 (15.2)
Program region (n¼148)
N/A, not available. Total, 153; 10 survey respondents completed no demographics information. The number varies within each category because not all respondents answered each question. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
Original Research
Resident coverage most often occurs without financial compensation or schedule rearrangement to reduce work hours at another time (45.4%). In 40.5% of programs, the resident on leave is expected to make up all missed call shifts; in 23.9% of programs, no make up work is required. Most program directors (82.8%) believed that becoming a parent negatively affected resident performance in some way. Limitation of scholarly activities was most cited (52.7%), with diminished timeliness (30.6%), less dedication to patient care (29.4%), and lower surgical volume (27.6%) after the leave. Of note, only 13.4% of program directors believed that becoming a parent resulted in diminished clinical skills. Approximately one-half of program directors believed that having a child in residency decreased well-being (50.9%); 19.0% believed that it increased resident well-being. The remaining directors were neutral or believed that the impact was mixed. Twelve program directors (7%) said they would advise against becoming a childbearing parent during residency. Last, most program directors (85.8%) believed new parenting is more challenging for female residents than for male residents, with 44.7% stating that it is more challenging for childbearing and nonchildbearing female residents alike; 41.7% of them stated that the greater challenge applied to childbearing female residents only. Regarding qualitative responses, programs directors most often used the freeresponse section to explain the reason that the ideal parental leave policies are usually more comprehensive than what their programs offered residents. The themes that were identified can be found in Table 3. The most common themes that arose from our qualitative analysis were conflicting policies (35.0%), work hour or policy barriers (32.5%), burden to co-residents (27.5%), limited resources (17.5%), and impaired training (15.0%; Table 3). Other notable themes that were identified were program director desire for more support (25.0%),
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e3
Original Research
ajog.org
EDUCATION
call for policy changes at the national level (12.5%), and enhanced well-being of parents (10.0%).
TABLE 2
Program director responses Questions and answers
Percentage of replies
Comment
Before this survey, were you aware of the July 2016 American College of Obstetricians and Gynecologists Policy Statement on paid parental leave? Yes
28.8
Aware of it, but not of its recommendations
26.4
No
44.8
Does your program have a formal policy regarding childbearing parental leave (commonly referred to as “maternity leave”)? Yes
82.8
No
9.8
Unsure
6.7
Does your program have a formal policy regarding nonchildbearing parental leave (commonly “paternity” or “partner” leave)? Yes
55.2
No
26.4
Unsure
17.2
Where can your parental leave policies be accessed? (multiple response) Publicly accessible online
17.2
Available on a private, password-protected intranet
41.1
Included in employment contracts
41.7
Included in recruitment materials provided at residency interviews
17.2
Available on request
53.4
Who covers for residents in your program who take parental leave? (multiple response) Other residents
98.8
Fellows, attending physicians
19.6
Moonlighters, hired coverage
3.7
Coverage typically not necessary
11.0
If residents cover for co-residents on leave: Do residents receive additional financial compensation for coverage? Yes
1.2
No, but their schedule is rearranged so that they work fewer hours at another time
47.2
No, residents cover without additional financial compensation or schedule rearrangement
45.4
Not applicable/unsure
4.9
At your residency program, is there flexibility to allow some rotations or calls to go uncovered by residents? Yes
54.0
No
45.4
Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
1.e4 American Journal of Obstetrics & Gynecology MONTH 2018
(continued)
Our study shows that, although nearly all program directors who responded have extended parental leave to their trainees, only 83% and 55% of programs have formal leave policies for childbearing and nonchildbearing parents, respectively. Most residency programs offer shorter parental leave than program directors think they should and do not meet ACOG’s recommendations on paid parental leave in residency. Several barriers to offering improved leave policies were raised and included the perceived negative effect of parenting in residency and the burden to covering for coresidents. The health and economic benefits of paid parental leave have been wellstudied and include lower rates of infant mortality, improved health for mother and child, and improved worker morale and retention.4,18-20 In the context of a national dialogue that aims to support women in the workplace through practices that include paid parental leave, lactation support, and a more family-friendly work environment, ACOG published a policy statement in 2016. In this communication, ACOG recommends 6 weeks of paid parental leave for residents, separate from sick or vacation time, and that trainees are not required to make up missed calls.15 This study quantitatively and qualitatively examined Obstetrics and Gynecology program directors’ attitudes regarding parental leave policies and their perceived effects of parenting during Obstetrics and Gynecology residency. Nearly two-thirds of all US Obstetrics and Gynecology programs are represented in the responses, which demonstrate ongoing interest in this subject that has been studied minimally in recent years. Our study shows that most training programs in Obstetrics and Gynecology fall short of meeting these recommendations. Although the statement provides ideas about the types of policies that residency programs should
ajog.org
EDUCATION
Original Research
FIGURE
TABLE 2
Ideal vs actual parental leave
Program director responses (continued) Questions and answers
Percentage of replies
Are residents who take parental leave required to make up missed call shifts? Yes, all shifts
40.5
Yes, some shifts
34.4
No
23.9
Are residents required to use available sick or vacation time as part of their parental leave? Yes
67.5
No
31.3
This is a comparison of the length of parental leave that childbearing and nonchildbearing trainees should “ideally” take and “usually” take. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
How much do you think becoming a parent affects an ObstetricsGynecology resident’s well-being during training? Increases significantly
4.9
Increases somewhat
14.1
Neutral effect
27.6
Decreases somewhat
37.4
Decreases significantly
13.5
In what ways does becoming a parent most negatively affect resident performance? (multiple selection, maximum 3) Not applicable; no appreciable negative impact
14.1
Diminished clinical skills
13.5
Less dedication to patient care
29.4
Limitation of scholarly activities
52.8
Diminished timeliness
30.7
Lower surgical volume
27.6
Total, 163. Percentages do not total 100 for multiple response questions or because not every respondent answered every question. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
offer, it offers little in terms of guidelines to implement them. In practice, most programs do not have equal leave policies for nonchildbearing resident parents, and 75% of the programs require residents to make up all or some of the call shifts missed while on leave, directly contradicting 1 of the main tenets of the statement. Of note, 44% of program directors were not aware of this guidance, raising the need for better dissemination. Although a minority of program directors expressed disapproval toward the ACOG policy statement’s ideals, most expressed a desire to offer policies more aligned with the statement’s guidelines. For both childbearing and nonchildbearing parents, programs offer less
leave time than directors think resident parents ought to have. In both quantitative and qualitative responses, a key issue cited is how American Board of Obstetrics and Gynecology guidelines constrain flexibility for program directors to allow for a 6-week minimum standard for parental leave. Specifically, American Board of Obstetrics and Gynecology delineates the maximum number of clinical weeks a trainee can miss without having to make up time. With the ongoing paradigm shift towards competency-based training, timebased residency requirements could be relaxed in to allow for compliance with the ACOG statement. Additionally, because parental leave policies are often not included in employment contracts
or, in one-half of cases, not even available upon request, 1 straightforward way to increase compliance with the statement is to increase prospective residents’ access to policy details. This access may help residents make better informed decisions when selecting residency programs and during family planning. Furthermore, it may also stimulate discussion and help the postgraduate medical community determine how best to enact such leave policies. In the 17 years since Davis et al7 published their study, there has been minimal change in the number of programs that offer parental leave in Obstetrics and Gynecology. In 2001, 80% and 69% of programs reported having formal childbearing and nonchildbearing leave policies, respectively.7 In our study, the numbers have changed only slightly, at 83% and 55%, respectively. Furthermore, in 2001, 77% of residents on parental leave were covered by other residents, and 37% of programs had the ability to leave shifts uncovered. Today, residents cover the shifts in 98.8% of the programs, despite 54% of programs reporting the ability to let some rotations or calls go uncovered. This suggests that, despite the implementation of work hour restrictions in the interim, residents have faced an increase in the coverage burden for residents on leave, which is an often cited concern. This issue is of paramount importance if parental leave policies are to succeed, because the small size of
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e5
Original Research
ajog.org
EDUCATION
TABLE 3
Themes identified in open-ended responses by domain queried Answers from program directors (n¼40) Conflicting policies at the national level (n¼14; 35.0%)
“I think it’s positive that ACOG and ACGME are more supportive in position statements and at meetings of residents and fellows becoming parents. However, we struggle.the requirements are complicated..so when residents are planning time off they are often confused by the different regulations and requirements of these different agencies.” “There is a very important distinction between rights and responsibilities as an employee and those as a trainee. ABOG requirements on trainees are the limiting factor in granting time off, not employee leave policies.”
Work hour/policy barriers (n¼13; 32.5%)
“The coverage schemes get stretched when one resident is away and other residents may become resentful so we ask people to make up their call. This makes it so that when residents come back from leave, they have a much more rigorous call schedule as they make up shifts, which is also not ideal as they have an infant at home.” “Having one or more residents out disrupts the training and work-load for all other remaining residents, especially in small programs, such as ours.”
Coverage burden to co-residents (n¼11; 27.5%)
“There are negative effects on the well-being of the residents that are left to cover for childbearing and nonchildbearing residents taking extended leave.” “Allowing this extremely liberal approach will create a logistical nightmare, and a truly unfair environment with regard to the male physicians (still at 20%), as well as those female physicians who defer childbearing.”
Program director desire for more support (n¼10; 25.0%)
“If Obstetrics and Gynecology isn’t family-friendly, then there is no hope for the other specialties.” “We unfortunately live in a world where we don’t practice what we preach. We advocate for our patients to get the time they need to start families, but our residents are left behind with suboptimal parental leave policies and minimal support.” “It is hard to believe that in the field of Obstetrics and Gynecology, policies that are more supportive of residents that have children during residency do not exist. Even worse that the view of the program and even other residents is that maternity leave is viewed as vacation time that will have to be paid in one way or the other.”
Limited resources (n¼7; 17.5%)
“All people in the United States need more family leave, period. Your problem is who will pay for it? We cannot afford to let everyone extend residency, as there is no money to do so...You either sacrifice for 4 years and wait or you find money to fund yourself to extend. This is not a matter of what is right or wrong- it’s a matter of finding the money to support.”
Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
some training programs, financial constraints, training requirements, and work-hour restrictions complicate
(continued)
coverage schemes. Larger programs may be able to use “swing” residents to cover new parents on leave or to let some
1.e6 American Journal of Obstetrics & Gynecology MONTH 2018
services go uncovered. This may allow some programs not to require new parents to make up missed call shifts. A small minority of programs reported hiring temporary staff to cover residents on leave, which is a practice that is common in other workplace settings that may help offer a more sustainable solution; however, funding this option may be prohibitive for some programs. In comparison with a 2016 study of General Surgery program directors, more Obstetrics and Gynecology directors in this study believed that parenting negatively affected resident performance (82.8% vs 61%) and were also more likely to say that new parenthood during residency negatively impacted well-being (51% vs 32%).10 This is consistent with respondents who cited that new parenthood affects female residents more than male residents and Obstetrics and Gynecology’s greater proportion of female trainees. Because medicine continues to embrace women in the workforce, we must adapt medical training to support this diversified workforce. Similar to when workhour restrictions were implemented, some stakeholders have expressed concern that more generous parental leave policies would come at the cost of graduate preparation. However, a study of Obstetrics and Gynecology residents showed that surgical volume was not affected by parental status.21 Although further studies may help clarify the perceived negative effect of parenthood on trainees, it is unlikely that residents will cease to build families in residency. Hence, we must focus on creating a work environment that can support resident parents, childbearing or not, as they complete their medical training. Studies show an increased risk of late pregnancy complication and pregnant trainees reported lack of support from fellow residents and their departments as the most stressful aspect of their pregnancy.22 This perceived lack of support, in the setting of inadequate parental leave policies, can lead residents to leave their programs before completing training and may be contributing to the 4.2% attrition rate that was seen in a recent study of
ajog.org
EDUCATION
TABLE 3
Themes identified in open-ended responses by domain queried (continued) Answers from program directors (n¼40) “I do not have the resources, both administrative and from the national organizations, to support parents to the degree that I believe we should. My residents must make up all calls because I don’t have funding to pay a moonlighter. This makes it so that they are working harder than their colleagues when they are pregnant, and then harder again after they come back from maternity/ paternity leave, both suboptimal in my opinion.” Impaired training of residents with “.no should someone get out of call because they had a children (n¼6; 15%) baby. You make up that call to your fellow residents. Some people need surgery or break bones or need to take care of sick parents or children- it’s all the same.” “Becoming a parent certainly takes away any extra time you would other spend at the hospital providing extra clinical care. Also, there is much less time for research and scholarly activities.” “Residents should be focused on residency during training. Having children, whether they are the childbearing parent or not, is a distraction and the best clinicians are focused on medicine. It also creates great financial pressure. I recommend my residents not start families while in residency because the burden is quite high.” Call for policy changes at the national level (n¼5; 12.5%)
“I hope that our national organizations, which are great at supporting mothers to be and mothers, extend that to their own trainees and that we advocate to provide better support to those who choose to build their families in residency.” “I think it is critical that we therefore adjust our expectations for residency to include parental leave and breastfeeding and accommodate accordingly.”
Enhances well-being of residents with children (n¼4; 10.0%)
“Having a child has a wonderful positive impact too.” “Being a parent increases an obstetrician/gynecologist’s ability to empathize with their patients and allows our trainees to live fulfilling personal lives outside the hospital.”
ABOG, American Board of Obstetrics and Gynecology; ACGME, Accreditation Council for Graduate Medical Education; ACOG, American College of Obstetricians and Gynecologists. Hariton et al. Parental leave policies in Obstetrics/Gynecology. Am J Obstet Gynecol 2018.
Obstetrics and Gynecology trainees.23 Failing to improve parental leave policies further poses a significant risk to the specialty, because highly qualified candidates may choose training programs or specialties that are more supportive of parent trainees. Given the expected shortfall of 8880 obstetricians and gynecologists in the workforce by 2020, it is especially important to establish competitive career paths with adequate work-life balance to our trainees as well as our practicing physicians.24
Major strengths of our study are our response rate (65.2%) and the dual quantitative and qualitative nature of our results. Our respondents are well distributed across Council on Resident Education in Obstetrics and Gynecology regions and program types, although we acknowledge that, with a higher response rate, our results would be more easily generalizable. Limitations to our study include possible response bias and limited demographic information for respondents, because not all directors
Original Research
provided this information. Response bias may account for the fact that 71.4% of respondents were female; only 58% of directors nationwide are; this may suggest a greater interest in the subject matter among female directors. Furthermore, our survey was validated previously in general surgery. After being adapted for Obstetrics and Gynecology respondents, it was tested with academic faculty only, so there may be survey bias in that our target population also included nonacademic program directors. Residency program directors face the challenges of supporting residents who choose to start families and protecting covering co-residents from becoming overburdened, all while ensuring adequate clinical training for all. Programs should, at a minimum, establish and make program policies available to current and future trainees. Although time-based residency training guidelines currently limit flexibility, a trend towards competency-based training and evaluation may allow for more creative solutions for program directors who seek to offer more robust parental leave policies and closer alignment with ACOG’s parental policy guidelines. Increasing the availability of affordable on-site child care and developing part-time training options may further help support new trainee parents.25 Ultimately, solutions will need to be tailored individually to a program’s structure and coverage needs. Although there are clear challenges in expanding paid parental leave coverage for trainees, there is also a significant cost of inaction. We hope our study serves to inform and catalyze more uniformity in parental leave for Obstetrics and Gynecology trainees nationwide. n Acknowledgments Britt J. Sandler (University of Washington) and Peter S. Yoo (Yale University) for their contributions to the creation of our survey tool.
References 1. Mundschenk M, Krauss EM, Poppler LH, et al. Resident perceptions on pregnancy during training: 2008 to 2015. Am J Surg 2016;212: 649-59. 2. Stentz NC, Griffith KA, Perkins E, DeCastro Jones R, Jagsi R. Fertility and childbearing
MONTH 2018 American Journal of Obstetrics & Gynecology
1.e7
Original Research
EDUCATION
among American female physicians. J Womens Health 2016;25:1059-65. 3. US Equal Employment Opportunity Commission. The Pregnancy Discrimination Act of 1978. Available at: https://www.eeoc.gov/laws/ statues/pregnancy.cfm. Accessed November 16, 2017. 4. Rossin M. The effects of maternity leave on children’s birth and infant health outcomes in the United States. J Health Econ 2011;30:221-39. 5. Avendano M, Berkman LF, Brugiavini A, Pasini G. The long-run effect of maternity leave benefits on mental health: evidence from European countries. Soc Sci Med 2015;132:45-53. 6. Baughman R, DiNardi D, Holtz-Eakin D. Productivity and wage effects of “family-friendly” fringe benefits. Int J Manpow 2003;24:247-59. 7. Davis JL, Baillie S, Hodgson CS, Vontver L, Platt LD. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol 2001;98:1093-8. 8. McPhillips HA, Burke AE, Sheppard K, Pallant A, Stapleton FB, Stanton B. Toward creating family-friendly work environments in pediatrics: baseline data from pediatrics department chairs and pediatrics program directors. Pediatrics 2007;119:596-602. 9. Weiss J, Teuscher D. What provisions do orthopaedic programs make for maternity, paternity, and adoption leave? Clin Orthop 2016;474:1945-9. 10. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. J Am Coll Surg 2016;222:1090-6. 11. Garza RM, Weston JS, Furnas HJ. Pregnancy and the plastic surgery resident. Plast Reconstr Surg 2017;139:245-52. 12. Accreditation Council for Graduate Medical Education (ACGME) Task Force on Quality Care
and Professionalism. The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development. Available at: http://www.acgme.org/Portals/ 0/PDFs/jgme-monograph[1].pdf. Accessed November 16, 2017. 13. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. 14. National LGBT Health Education Center. Pathways to Parenthood for LGBT People. Available at: http://www.lgbthealtheducation. org/wp-content/uploads/Pathways-to-Parenthood -for-LGBT-People.pdf. Accessed November 16, 2017. 15. The American College of Obstetricians and Gynecologists. Statement of Policy: Paid Parental Leave. July 2016. Available at: https://www.acog.org/media/Statements-ofPolicy/Public/92ParentalLeaveJuly16.pdf?dmc ¼1&ts¼20161112T1513227627. Accessed November 16, 2017. 16. Residency Program Directory by Region. Available at: http://www.acog.org/AboutACOG/ACOG-Departments/CREOG/CREOGSearch/Residency-Program-Directory-by-Regions. Accessed January 15, 2016. 17. Residency Directory Search. Available at: https://www.apgo.org/component/residence directory. Accessed January 15, 2016. 18. Ruhm CJ. Parental leave and child health. J Health Econ 2000;19:931-60. 19. Berger LM, Hill J, Waldfogel J. Maternity leave, early maternal employment and child health and development in the US. Econ J 2005;115:F29-47. 20. Gault B, Hartmann H, Hegewisch A, Mili J, Reichlin L. Paid parental leave in the United States: what the data tell us about access, usage, and economic and health benefits. Washington, DC: Institute for Women’s Policy Research. 2014. Available
1.e8 American Journal of Obstetrics & Gynecology MONTH 2018
ajog.org at: http://www.iwpr.org/publications/pubs/ paid-parental-leave-in-the-united-states-what-thedata-tell-us-about-access-usage-and-economicand-health-benefits/. Accessed August 27, 2017. 21. Lashbrook DL, Frazier LM, Horbelt DV, Stembridge TW, Rall MJ. Pregnancy during obstetrics and Gynecology residency: effect on surgical experience. Am J Obstet Gynecol 2003;189:662-5. 22. Finch SJ. Pregnancy during residency: a literature review. Acad Med 2003;78:418-28. 23. Waldman JD, Kelly F, Arora S, Smith HL. The shocking cost of turnover in health care. Health Care Manage Rev 2004;29:2-7. 24. Rayburn W. The Obstetrician-Gynecologist Workforce in the United States; Facts, Figures, and Implications. Washington, DC: American College of Obstetricians and Gynecologists; 2011. 25. Jagsi R, Tarbell NJ, Weinstein DF. Becoming a doctor, starting a family — leaves of absence from graduate medical education. N Engl J Med 2007;357:1889-91.
Author and article information From the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (Drs Hariton, Burns, and Berkowitz); the Department of Obstetrics, Gynecology and Reproductive Biology, Brigham & Women’s Hospital, Harvard Medical School (Drs Hariton and Burns); the Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine (Dr Matthews); and the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center (Dr Akileswaran), Boston, MA. Received Feb. 7, 2018; revised April 9, 2018; accepted April 10, 2018. The authors report no conflict of interest. Corresponding author: Eduardo Hariton, MD, MBA. [email protected]