- Email: [email protected]
Pregnancy and Parenthood among Surgery Residents: Results of the First Nationwide Survey of General Surgery Residency Program Directors
Pregnancy and Parenthood among Surgery Residents: Results of the First Nationwide Survey of General Surgery Residency Program Directors Britt J Sandler,
MHS,
John J Tackett,
MD, MHS,
Walter E Longo,
MD, FACS,
Peter S Yoo,
MD, FACS
Although family and lifestyle are known to be important factors for medical students choosing a specialty, there is a lack of research about general surgery residency program policies regarding pregnancy and parenthood. Similarly, little is known about program director attitudes about these issues. STUDY DESIGN: We performed a cross-sectional survey of United States (US) general surgery residency program directors. RESULTS: Sixty-six respondents completed the survey: 70% male, 59% from university-based programs, and 76% between 40 and 59 years of age. Two-thirds (67%) reported having a maternity leave policy. Less than half (48%) reported having a leave policy for the non-childbearing parent (paternity leave). Leave duration was most frequently reported as 6 weeks for maternity leave (58%) and 1 week for paternity leave (45%). Thirty-eight percent of general surgery residency program directors (PDs) reported availability of on-site childcare, 58% reported availability of lactation facilities. Forty-six percent of university PDs said that the research years are the best time to have a child during residency; 52% of independent PDs said that no particular time during residency is best. Sixty-one percent of PDs reported that becoming a parent negatively affects female trainees’ work, including placing an increased burden on fellow residents (33%). Respondents perceived children as decreasing female trainees’ well-being more often than male trainees’ (32% vs 9%, p < 0.001). CONCLUSIONS: Program director reports indicated a lack of national uniformity in surgical residency policies regarding parental leave, length of leave, as well as inconsistency in access to childcare and availability of spaces to express and store breast milk. Program directors perceived parenthood to affect the training and well-being of female residents more adversely than that of male residents. (J Am Coll Surg 2016;222:1090e1096. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
Surgical training, especially with an increasing trend toward fellowship training in a subspecialty, is lengthy and overlaps with the most common childbearing years. Disclosure Information: Nothing to disclose. Support: Work supported by the Office of Student Research and the Section of Surgical Education, Department of Surgery, Yale School of Medicine. Presented at the 96th Annual Meeting of the New England Surgical Society, Newport, RI, September 2015. Received October 23, 2015; Revised December 7, 2015; Accepted December 8, 2015. From the Department of Surgery, Yale School of Medicine, New Haven, CT. Correspondence address: Peter S Yoo, MD, FACS, PO Box 208062, FMB 121, New Haven, CT 06520. email: [email protected]
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
A surgical trainee on a traditional path is likely to graduate college at age 22, medical school at 26, complete a 7-year academic residency at 33, and finish a 2-year fellowship at age 35. National statistics reveal that even among the most highly educated women (those with a master’s degree or higher), 80% have had their first child by age 34.1 Previous research has shown that women surgeons are significantly more likely than their male peers to delay parenthood until after training.2 But for many trainees, it may not be desirable or feasible to postpone starting a family until they are in practice. Demographic shifts among medical trainees make these issues increasingly relevant, as women now comprise half of medical school graduates and more than 40% of
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general surgery residents. Generational and societal changes also affect men or non-childbearing parents in terms of desire for time and involvement with family. Despite the knowledge that family and lifestyle priorities are important factors in specialty selection, there is a dearth of research about how general surgery residency programs accommodate pregnancy and parenthood among trainees. This is the first US nationwide survey of general surgery residency program directors (PDs) addressing pregnancy and parenthood during surgical training.
METHODS A 31-question survey was distributed electronically to all active members of the Association of Program Directors in Surgery (APDS). The survey was developed through a comprehensive multistage method.3 The first step involved in-depth qualitative interviews with surgical residents who are parents at the authors’ home program to identify key themes and issues. Questions were drafted to address these key issues, and were reviewed by colleagues with expertise in qualitative research. The survey was pilot tested with a small group of program directors and associate program directors, and subsequently, a final check was performed. The Association of Program Directors in Surgery Committee on Research and the Yale University Human Investigations Committee approved the project. Respondents were asked about their demographics (sex, age, parental status), program information (size, geographic region, university-based or independent status, resident sex, and resident parental status), the existence of program policies regarding parental leave, issues surrounding childcare and breastfeeding, timing of pregnancy during residency, and perceptions of the impact of parenthood on resident training and well-being. Data were collected using Qualtrics (Qualtrics) and analyzed using Stata 14.0 (StataCorp). Analysis was performed using Fisher’s exact test for categorical variables and the Z-test of proportions. RESULTS Sixty-six program directors (PDs) completed the survey, comprising 26% of the 255 ACGME-accredited general surgery residency programs (Table 1). Respondents were 30% female (vs 16% female for all ACGME programs). Seventy-six percent were between 40 and 59 years old, 53% had been program director at their current program for less than 5 years, and 81% had been in their role for less than 10 years. Of male program directors, 85% reported having children, while 65% of female PDs reported having children (p ¼ 0.102). The majority of
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Table 1. Demographic Characteristics of Program Director Survey Respondents Men %
Women n %
Characteristic
n
Total Age, y 30e39 40e49 50e59 60e69 70 Children Yes No Children born by stage of training During medical school During residency During fellowship As an attending Years in practice 0e5 6e10 11e15 16e20 21e25 26e30 >30 Years as a program director 0e5 6e10 11e15 16e20 >20
46 69.7 20 30.3
p Value
0.260 2 4.4 1 5.0 15 32.6 12 60.0 17 37.0 6 30.0 10 21.7 1 5.0 1 2.2 0 0.0 0.102 39 84.8 13 65.0 7 15.2 7 35.0 6 25 8 23 1 8 8 7 11 6 5 24 12 5 2 2
13.0 0 0.0 0.103 54.3 1 5.0 <0.001 17.4 2 10.0 0.359 50.0 11 55.0 0.458 0.233 2.2 1 5.0 17.4 8 40.0 17.4 5 25.0 15.2 3 15.0 23.9 2 10.0 13.0 1 5.0 10.9 0 0.0 0.834 52.2 11 55.0 26.1 5 25.0 10.9 4 20.0 4.4 0 0.0 4.4 0 0.0
Sixty-six program directors responded to the survey, comprising 26% of the ACGME-accredited general surgery residency programs. Respondents were 30% female (vs 16% female for all ACGME programs), and 81% had been in their role for less than 10 years. Of male PDs, 85% reported having children, while 65% of female PDs reported having children (p ¼ 0.102). The majority of male PDs (54%) had children born during residency, while only 1 female PD had a child born during residency (5%) (p < 0.001).
male PDs (54%) had children born during residency, while only 1 female PD had a child born during residency (5%) (p < 0.001). Program size was defined by the annual number of graduating chief residents in categorical general surgery slots (Table 2). Twenty-nine percent of programs had 1 to 3 graduating chiefs per year, 44% had 4 to 6, and 27% had 7 or more. The majority of respondents represented university-based programs (59%) vs independent programs (41%), which is consistent with the national distribution of residency programs (65% university-based). The majority of PDs reported having a relatively even sex distribution
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Table 2.
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Pregnancy and Parenthood in Surgical Residency
Residency Program Characteristics
Characteristic
n
%
Total No. of chief residents 1e3 4e6 7e9 10 Type of program Independent University Geographic region Midwest Northeast South West Percentage of female residents 0e20 21e40 41e60 61e80 81e100 Percentage of residents with children 0e20 21e40 41e60 61e80 81e100
66
100.0
19 29 16 2
28.8 43.9 24.2 3.0
27 39
40.9 59.1
22 21 13 10
33.3 31.8 19.7 15.2
4 19 38 4 0
6.1 28.8 57.6 6.1 0.0
16 32 16 2 0
24.2 48.5 24.2 3.0 0.0
Respondents represented a broad distribution of program sizes and geographic areas. The majority of responding program directors represented university-based programs, which is consistent with the national distribution (65% university-based). Most program directors reported an even sex distribution among residents (58% report 41% to 60% female residents), and 76% of program directors reported that at least 20% of their residents have children.
among their residents, with 58% reporting 41% to 60% female residents. Only 2 PDs (3%) reported that none of their current residents had children, and the majority of PDs (76%) reported that at least 20% of their residents had children. Scheduling parental leave is a common occurrence for program directors. Forty-one percent of PDs reported making arrangements for leave on at least a yearly basis. In terms of formal policies regarding parental leave, twothirds (67%) of PDs reported having a formal maternity leave policy. Less than half (48%) of PDs reported having a paternity leave policy. (In the survey, the colloquial term paternity leave was defined as leave taken by the nonchildbearing parent, also referred to as secondary caregiver leave, and is used interchangeably here for linguistic simplicity). Regardless of the existence of formal policies, most PDs (58%) reported that residents who give birth
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are typically provided with 6 weeks of maternity leave (Fig. 1). The most common length of leave for the nonchildbearing parent is either 1 (45%) or 2 (27%) weeks. University-based programs are more likely to have policies in place for the non-child bearing parent (59% vs 33%, p ¼ 0.044). Larger programs are more likely to have such leave policies: 72% of programs with more than 6 residents had a formal paternity leave policy, while only 40% of programs with 6 or fewer residents had one (p ¼ 0.05). Larger programs also make arrangements for leave more frequently (p ¼ 0.001). Program size is not significantly associated with the presence of maternity leave policies or the length of maternity or paternity leave provided. Qualitative interviews revealed that issues surrounding breastfeeding and childcare are common stressors for residents with children. Residents interviewed emphasized the personal importance of providing their infants with breast milk given long work hours and time away from their child, but expressed difficulty in finding time to express breast milk during the workday. Five PDs (8%) reported having a formal policy regarding breastfeeding; however, 77% of PDs stated that a typical attending at their program would permit a resident to scrub out of a case to pump, 58% reported the availability of lactation facilities in their hospitals. Programs located in the Northeast are less likely to have lactation spaces available than in other parts of the country (29%, vs 71% for all other regions, p ¼ 0.037). Arranging childcare was identified as a significant challenge. Although 14% of PDs were unaware of their residents’ childcare arrangements, others reported that most residents’ children were either in daycare (32%) or cared for by a stay-at-home spouse (27%) or nanny (14%). Thirty-eight percent of PDs reported the presence of on-site childcare at their hospitals. In qualitative interviews, residents expressed frustration with limited availability of slots at on-site childcare centers and with daycare drop-off and pick-up times that were incompatible with their daily schedule. Interviews also revealed that, to the extent possible, residents attempt to plan for a “convenient” time during residency to have a child. Program directors were asked when the best time during residency for a trainee to have a child is. Among university PDs, 46% said that the lab years are the best time to have a child during residency; 52% of independent residency PDs said that no particular time during residency is best. Overall, 15% of PDs say they would advise against having a child during residency. In qualitative interviews, residents who were parents recalled feeling apprehensive about how they would be viewed. Residents who had become pregnant expressed concerns about “being a burden on colleagues,” “being
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Figure 1. Typical length of parental leave provided for residents. (A) Maternity leave length, in weeks. (B) Paternity leave length, in weeks. Responses to survey question, “How much time are residents typically allotted for [maternity/paternity] leave?” Regardless of the existence of formal policies, most program directors (58%) reported that residents who give birth are allotted 6 weeks of maternity leave. Paternity leave was most commonly reported as 1 (45%) or 2 (27%) weeks.
perceived as lazy” or “not carrying my weight,” and “being treated differently than my peers.” Male residents described guilt at leaving their teams shorthanded while on paternity leave, saying, “the good residents take as little time as possible.” When asked about the effects of parenthood on residents, 61% of PDs reported that becoming a parent negatively affects female trainees’ work, including by placing an increased burden on fellow residents (33%), as well as negatively affecting scholarly activities (9%), clinical activities (8%), dedication to patient care (6%), and timeliness (5%) (Fig. 2). Program directors were significantly less likely to say that becoming a parent negatively affects male trainees’ work (34% vs 61%, p ¼ 0.003). Similarly, respondents perceived children as decreasing female residents’ well-being more often than male residents’ (32% vs 9%, p < 0.001) (Fig. 3).
DISCUSSION As the demographics of surgical practice evolve, it is imperative to understand the role that pregnancy and parenthood play among surgical trainees. Despite parenthood being common among surgical trainees, there is a lack of consistency across programs nationwide in the existence of parental leave policies after the birth of a child, and variability in the length of maternity and paternity leave provided. Beyond the post-partum period, these results demonstrate inconsistency in the availability of onsite childcare and the ability to continue breastfeeding, which requires access to lactation facilities and break time to express breast milk. These findings are also notable for the program director perception that becoming a parent more negatively affects the training and well-being of female residents.
Figure 2. Program director attitudes regarding negative effects of parenthood on residents’ work, stratified by resident sex. Responses to survey question, “Beyond [maternity/paternity] leave, in what way does having a baby most negatively affect the work of a [female/male] trainee?” Program directors were significantly more likely to report that becoming a parent negatively affects female trainees’ work in 1 of 5 dimensions than male trainees’ work (61% vs 34%, p ¼ 0.003).
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Figure 3. Program director attitudes regarding the impact of parenthood on resident well-being, stratified by resident sex. Responses to survey question, “How much do you think having children affects a [male/female] resident’s well-being during training?” Thirty-two percent of program directors reported that children decrease female residents’ well-being vs 9% for male residents (p < 0.001).
The changing demographics of the surgical workforce make these issues timely. In 2014, 41% of general surgery residents were female, while 48% of medical school matriculants were women.4,5 These issues are not only relevant to the growing number of women joining the surgical profession. Studies show that fathers today are more involved in parenting than at any time in the recent past.6 Changing societal and gender norms have resulted in more dual-earner professional families and greater expectations that men are active and involved parents. Residents of both sexes expressed in qualitative interviews that time away from their children and inability to contribute equally to the work of parenting contributed to feelings of guilt and conflict with their partners. Furthermore, families with parents of the same sex require careful consideration of the traditional terminology of maternity and paternity. For the purpose of linguistic simplicity, the traditional terminology was used in this manuscript, but the authors fully acknowledge the limitations and potential bias associated with this taxonomy. With ongoing societal changes including the recent Supreme Court Ruling on Obergefell v. Hodges, making same-sex marriage legal in the US, nontraditional parenting situations requiring new and thoughtfully crafted solutions may arise. In this regard, program directors will need to remain open to addressing the evolving family needs of their trainees. These findings are also relevant to discussions around maintaining the future surgical workforce and the recruitment of talented medical students. Studies of specialty selection among medical students have demonstrated that students perceive surgical careers to pose challenges to raising children.7 Furthermore, lifestyle factors play into both specialty choice and the 20% attrition rate among
surgical residents.7-9 Talented students may opt out of pursuing surgery because they wish to be parents and view surgical training as incompatible with pregnancy and childrearing. Although just 15% of program directors surveyed said they would advise a trainee not to have a child during residency, it is possible that subtle discouragement occurs in other ways. A single institution survey of post-match fourth year medical students reported that 90% were asked potentially discriminatory questions during residency interviews, including being asked their marital status and whether they had children. Of the students applying to surgical residencies, 50% were asked about plans for pregnancy, while only 14% of nonsurgical applicants were asked (p ¼ 0.057).10 It is important to view these findings in the context of other medical specialties. As early as 1989, the American College of Physicians published a position paper urging internal medicine programs to create written policies on parental leave.11 A 2007 survey of pediatrics programs showed that 90% had maternity leave policies in place.12 Obstetrics and gynecology is a specialty with a high proportion of female trainees and a demanding schedule. A 2001 survey of these residency programs revealed that 80% and 69% had maternity and paternity leave policies, respectively, and it is reasonable to speculate that these rates have since increased.13 We encourage surgical residency programs without leave policies in place to consider creating guidelines that are compatible with their program and appropriate to their residents’ needs. Doing so may reduce the apprehension that residents feel in addressing these needs, and allow for predictability in planning for parental leave. Moreover, the existence of such guidelines is relevant to
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the recruitment of future trainees. Students should be able to know, in advance of matching at a program, whether their basic needs will be met in the event of becoming a parent. Such guidelines will allow applicants to rank programs based on educational goals rather than lifestyle needs. We further encourage residency programs to be attentive to the well-being of their trainees who are parents. In the 2008 National Study of Expectations and Attitudes of Residents in Surgery (NEARS), residents with children reported higher levels of strain on their family life relative to married residents without children.7 Parental leave after the birth of a child is only 1 component of the many stressors trainees face in parenting during residency. Longer-term issues, such as access to childcare and the option to continue breastfeeding, are key. Just 38% of PDs report the availability of on-site childcare. Where on-site daycare is available, residents may face waiting lists to enroll, and pick up and drop off times that are incompatible with their work schedules. Residents in qualitative interviews spoke specifically about the need for their spouses to make career sacrifices to comport with daycare schedules, and their frustrations with long waiting lists for on-site care. Where possible, programs may wish to leverage their institutions to provide resources like childcare subsidies, backup care in the event of a child’s illness, or after-hours care.14 The American Academy of Pediatrics15 recommends that infants be exclusively fed breast milk for the first 6 months of life and that breastfeeding continue until at least 1 year of age. Residents identified the inability to meet their own goals for breastfeeding to be a significant source of stress and disappointment. The Affordable Care Act (ACA)16 requires employers to provide lactation facilities and break time to pump; however, less than 60% of PDs reported the availability of lactation spaces in their hospitals. Although most PDs reported that a typical attending would permit a resident to scrub out of a case to pump, residents may not feel empowered to make such a request, though delays in expressing breast milk can result in pain, leakage, infection, and decrease in milk supply. Programs may wish to work with their hospitals to ensure compliance with Affordable Care Act provisions, and to explicitly offer break time for breastfeeding residents to pump if patient care permits. A notable finding of this survey is the program director perception that parenthood more negatively affects women’s well-being. Undoubtedly, pregnancy and birth place a greater physical burden on women, and studies of pregnant physicians have shown rates of pregnancy complications similar to those in women who work other
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physically demanding jobs, including increased risk of preterm delivery and pre-eclampsia.17 However, beyond the duration of pregnancy and maternity leave, this becomes a multidimensional issue. The NEARS study demonstrated that male surgical residents were actually more likely to report satisfaction with their work if they were married or had children, and that marriage served to increase both confidence and happiness at work.7 Women, by contrast, expressed feeling overwhelmed after giving birth, and reported concerns about their reputation at work after simply getting married.18 The findings described here should be considered in light of the limitations of self-reported surveys. Despite the assurance of strict anonymity, program directors may have chosen their responses to avoid expressing controversial opinions or placing their residency program in an unflattering light. Further, the surveyed sample of program directors (26% of PDs nationwide) may not be representative of the total population of PDs. This sample is over-representative of both female PDs (30%, vs 16% nationwide) and programs with a large proportion of female residents (nationally, 40% of general surgery residents are women, but here, 64% of PDs reported that more than 40% of their residents were female). It is unclear in which way these factors may have biased the results.
CONCLUSIONS The length and rigor of surgical residency is necessary to train skilled surgeons, particularly in the setting of limitations on duty hours. A move toward competency-based education, rather than strict quotas of weeks worked, may provide additional flexibility for residents. However, the suggestions offered above would improve parenting trainees’ quality of life and continue to attract talented students into the field without sacrificing educational rigor. Overall, PD reports indicated a lack of uniformity in surgical residency policies regarding parental leave, as well as inconsistency in access to childcare and availability of lactation facilities. Notably, PDs perceived parenthood to more negatively affect the training and well-being of female residents. These findings are relevant to the recruitment of surgical residents and maintenance of the future surgical workforce. We encourage program directors to be attentive to the well-being of trainees who are parents and, where possible, work to improve availability of childcare and lactation facilities. Programs without leave policies in place may wish to create formal guidelines to ensure predictability for their trainees.
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Invited Commentary
Author Contributions Study conception and design: Sandler, Tackett, Longo, Yoo Acquisition of data: Sandler, Tackett Analysis and interpretation of data: Sandler, Tackett, Yoo Drafting of manuscript: Sandler, Tackett, Yoo Critical revision: Sandler, Tackett, Longo, Yoo
16. Patient Protection and Affordable Care Act. 42 USC x 18001 et seq (2010). 17. Finch SJ. Pregnancy during residency: a literature review. Acad Med 2003;78:418e428. 18. Chen MM, Yeo HL, Roman SA, et al. Life events during surgical residency have different effects on women and men over time. Surgery 2013;154:162e170.
REFERENCES 1. Livingston G. For most highly educated women, motherhood doesn’t start until the 30s. Washington, DC. Available at: http://www.pewresearch.org/fact-tank/2015/01/15/for-mosthighly-educated-women-motherhood-doesnt-start-until-the-30s/. Accessed July 6, 2015. 2. Troppmann KM, Palis BE, Goodnight JE Jr, et al. Women surgeons in the new millennium. Arch Surg 2009;144:635e642. 3. Dillman DA, Smyth JD, Christian LM. Internet, Mail, and Mixed-Mode Surveys: The Tailored Design Method. 3rd ed. Hoboken: Wiley; 2009. 4. AAMC. Number of active residents by type of medical school graduation, GME specialty, and gender. Washington, DC. Available at: https://www.aamc.org/data/421322/tableb2.html. Accessed July 7, 2015. 5. AAMC. U.S. medical school applications and matriculants by school, state of legal residence, and sex. Washington, DC: 2014. Available at: https://www.aamc.org/download/321442/ data/factstable1.pdf. Accessed July 7, 2015. 6. Parker K, Wang W. Roles of moms and dads converge as they balance work and family. Washington, DC. Available at: http:// www.pewsocialtrends.org/2013/03/14/modern-parenthood-rolesof-moms-and-dads-converge-as-they-balance-work-and-family/. Accessed July 7, 2015. 7. Sullivan MC, Yeo H, Roman SA, et al. Striving for work-life balance: effect of marriage and children on the experience of 4402 US general surgery residents. Ann Surg 2013;257:571e576. 8. Yeo H, Bucholz E, Ann Sosa J, et al. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg 2010;252:529e534; discussion 534e536. 9. Brown EG, Galante JM, Keller BA, et al. Pregnancyrelated attrition in general surgery. JAMA Surg 2014;149: 893e897. 10. Santen SA, Davis KR, Brady DW, Hemphill RR. Potentially discriminatory questions during residency interviews: frequency and effects on residents’ ranking of programs in the national resident matching program. J Grad Med Educ 2010;2: 336e340. 11. Parental leave for residents. American College of Physicians. Ann Int Med 1989;111:1035e1038. 12. McPhillips HA, Burke AE, Sheppard K, et al. Toward creating family-friendly work environments in pediatrics: baseline data from pediatric department chairs and pediatric program directors. Pediatrics 2007;119:e596ee602. 13. Davis JL, Baillie S, Hodgson CS, et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol 2001;98:1093e1098. 14. Key LL Jr. Child care supplementation: aid for residents and advantages for residency programs. J Pediatrics 2008;153: 449e450. 15. Breastfeeding and the use of human milk. Pediatrics 2012;129: e827ee841.
Invited Commentary James F Whiting, Portland, ME
MD, FACS
Dr Sandler and colleagues report on a survey of program directors conducted to ascertain attitudes and policies around pregnancy and child rearing during surgical residency. The study was well constructed, with uncommon thought and effort given to its design. It was administered and reviewed by the Association of Program Directors in Surgery (APDS) research committee, a system designed to highlight surveys of exceptional value to all of us experiencing “survey fatigue”; then it was distributed online. The results paint a clear picture of the current state of surgical residencies, and the conclusions and discussion are illuminating and important. Only 1 thing is missing: Where is the outrage? Only 26% of program directors chose to complete this survey, despite it arriving with the imprimateur of the APDS research committee. Of those who did complete it, only 38% of programs reported providing childcare options. A little more than half provided lactation facilities, and incredible as it may seem, in an era in which an individual’s every thought and action in a modern residency feel like they must be documented, fully one-third of programs did not even have a policy on maternity leave. This is shameful, and it is all of our shared responsibility to change it. Warren Buffett is famously reported to have attributed a portion of his investing success to the fact that he was only competing against half of the population. Is this what we want for surgery? If we want to encourage the best and the brightest to enter our field, we need to be leaders in creating opportunities for women in surgery, not stragglers grudgingly giving in to societal pressures. Maternity leave policies, lactation facilities, and childcare are the lowest of low hanging fruit. The availability of childcare may be rare in most training programs, but look at the 12 health care organizations that made it into Fortune magazine’s top 100 workplaces in 2015. Ten of those 12 organizations offer childcare and most of them subsidize it. All of them provide lactation facilities and all of them have detailed and generous policies around maternity leave.
MHS,
John J Tackett,
MD, MHS,
Walter E Longo,
MD, FACS,
Peter S Yoo,
MD, FACS
Although family and lifestyle are known to be important factors for medical students choosing a specialty, there is a lack of research about general surgery residency program policies regarding pregnancy and parenthood. Similarly, little is known about program director attitudes about these issues. STUDY DESIGN: We performed a cross-sectional survey of United States (US) general surgery residency program directors. RESULTS: Sixty-six respondents completed the survey: 70% male, 59% from university-based programs, and 76% between 40 and 59 years of age. Two-thirds (67%) reported having a maternity leave policy. Less than half (48%) reported having a leave policy for the non-childbearing parent (paternity leave). Leave duration was most frequently reported as 6 weeks for maternity leave (58%) and 1 week for paternity leave (45%). Thirty-eight percent of general surgery residency program directors (PDs) reported availability of on-site childcare, 58% reported availability of lactation facilities. Forty-six percent of university PDs said that the research years are the best time to have a child during residency; 52% of independent PDs said that no particular time during residency is best. Sixty-one percent of PDs reported that becoming a parent negatively affects female trainees’ work, including placing an increased burden on fellow residents (33%). Respondents perceived children as decreasing female trainees’ well-being more often than male trainees’ (32% vs 9%, p < 0.001). CONCLUSIONS: Program director reports indicated a lack of national uniformity in surgical residency policies regarding parental leave, length of leave, as well as inconsistency in access to childcare and availability of spaces to express and store breast milk. Program directors perceived parenthood to affect the training and well-being of female residents more adversely than that of male residents. (J Am Coll Surg 2016;222:1090e1096. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
Surgical training, especially with an increasing trend toward fellowship training in a subspecialty, is lengthy and overlaps with the most common childbearing years. Disclosure Information: Nothing to disclose. Support: Work supported by the Office of Student Research and the Section of Surgical Education, Department of Surgery, Yale School of Medicine. Presented at the 96th Annual Meeting of the New England Surgical Society, Newport, RI, September 2015. Received October 23, 2015; Revised December 7, 2015; Accepted December 8, 2015. From the Department of Surgery, Yale School of Medicine, New Haven, CT. Correspondence address: Peter S Yoo, MD, FACS, PO Box 208062, FMB 121, New Haven, CT 06520. email: [email protected]
ª 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
A surgical trainee on a traditional path is likely to graduate college at age 22, medical school at 26, complete a 7-year academic residency at 33, and finish a 2-year fellowship at age 35. National statistics reveal that even among the most highly educated women (those with a master’s degree or higher), 80% have had their first child by age 34.1 Previous research has shown that women surgeons are significantly more likely than their male peers to delay parenthood until after training.2 But for many trainees, it may not be desirable or feasible to postpone starting a family until they are in practice. Demographic shifts among medical trainees make these issues increasingly relevant, as women now comprise half of medical school graduates and more than 40% of
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general surgery residents. Generational and societal changes also affect men or non-childbearing parents in terms of desire for time and involvement with family. Despite the knowledge that family and lifestyle priorities are important factors in specialty selection, there is a dearth of research about how general surgery residency programs accommodate pregnancy and parenthood among trainees. This is the first US nationwide survey of general surgery residency program directors (PDs) addressing pregnancy and parenthood during surgical training.
METHODS A 31-question survey was distributed electronically to all active members of the Association of Program Directors in Surgery (APDS). The survey was developed through a comprehensive multistage method.3 The first step involved in-depth qualitative interviews with surgical residents who are parents at the authors’ home program to identify key themes and issues. Questions were drafted to address these key issues, and were reviewed by colleagues with expertise in qualitative research. The survey was pilot tested with a small group of program directors and associate program directors, and subsequently, a final check was performed. The Association of Program Directors in Surgery Committee on Research and the Yale University Human Investigations Committee approved the project. Respondents were asked about their demographics (sex, age, parental status), program information (size, geographic region, university-based or independent status, resident sex, and resident parental status), the existence of program policies regarding parental leave, issues surrounding childcare and breastfeeding, timing of pregnancy during residency, and perceptions of the impact of parenthood on resident training and well-being. Data were collected using Qualtrics (Qualtrics) and analyzed using Stata 14.0 (StataCorp). Analysis was performed using Fisher’s exact test for categorical variables and the Z-test of proportions. RESULTS Sixty-six program directors (PDs) completed the survey, comprising 26% of the 255 ACGME-accredited general surgery residency programs (Table 1). Respondents were 30% female (vs 16% female for all ACGME programs). Seventy-six percent were between 40 and 59 years old, 53% had been program director at their current program for less than 5 years, and 81% had been in their role for less than 10 years. Of male program directors, 85% reported having children, while 65% of female PDs reported having children (p ¼ 0.102). The majority of
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Table 1. Demographic Characteristics of Program Director Survey Respondents Men %
Women n %
Characteristic
n
Total Age, y 30e39 40e49 50e59 60e69 70 Children Yes No Children born by stage of training During medical school During residency During fellowship As an attending Years in practice 0e5 6e10 11e15 16e20 21e25 26e30 >30 Years as a program director 0e5 6e10 11e15 16e20 >20
46 69.7 20 30.3
p Value
0.260 2 4.4 1 5.0 15 32.6 12 60.0 17 37.0 6 30.0 10 21.7 1 5.0 1 2.2 0 0.0 0.102 39 84.8 13 65.0 7 15.2 7 35.0 6 25 8 23 1 8 8 7 11 6 5 24 12 5 2 2
13.0 0 0.0 0.103 54.3 1 5.0 <0.001 17.4 2 10.0 0.359 50.0 11 55.0 0.458 0.233 2.2 1 5.0 17.4 8 40.0 17.4 5 25.0 15.2 3 15.0 23.9 2 10.0 13.0 1 5.0 10.9 0 0.0 0.834 52.2 11 55.0 26.1 5 25.0 10.9 4 20.0 4.4 0 0.0 4.4 0 0.0
Sixty-six program directors responded to the survey, comprising 26% of the ACGME-accredited general surgery residency programs. Respondents were 30% female (vs 16% female for all ACGME programs), and 81% had been in their role for less than 10 years. Of male PDs, 85% reported having children, while 65% of female PDs reported having children (p ¼ 0.102). The majority of male PDs (54%) had children born during residency, while only 1 female PD had a child born during residency (5%) (p < 0.001).
male PDs (54%) had children born during residency, while only 1 female PD had a child born during residency (5%) (p < 0.001). Program size was defined by the annual number of graduating chief residents in categorical general surgery slots (Table 2). Twenty-nine percent of programs had 1 to 3 graduating chiefs per year, 44% had 4 to 6, and 27% had 7 or more. The majority of respondents represented university-based programs (59%) vs independent programs (41%), which is consistent with the national distribution of residency programs (65% university-based). The majority of PDs reported having a relatively even sex distribution
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Table 2.
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Residency Program Characteristics
Characteristic
n
%
Total No. of chief residents 1e3 4e6 7e9 10 Type of program Independent University Geographic region Midwest Northeast South West Percentage of female residents 0e20 21e40 41e60 61e80 81e100 Percentage of residents with children 0e20 21e40 41e60 61e80 81e100
66
100.0
19 29 16 2
28.8 43.9 24.2 3.0
27 39
40.9 59.1
22 21 13 10
33.3 31.8 19.7 15.2
4 19 38 4 0
6.1 28.8 57.6 6.1 0.0
16 32 16 2 0
24.2 48.5 24.2 3.0 0.0
Respondents represented a broad distribution of program sizes and geographic areas. The majority of responding program directors represented university-based programs, which is consistent with the national distribution (65% university-based). Most program directors reported an even sex distribution among residents (58% report 41% to 60% female residents), and 76% of program directors reported that at least 20% of their residents have children.
among their residents, with 58% reporting 41% to 60% female residents. Only 2 PDs (3%) reported that none of their current residents had children, and the majority of PDs (76%) reported that at least 20% of their residents had children. Scheduling parental leave is a common occurrence for program directors. Forty-one percent of PDs reported making arrangements for leave on at least a yearly basis. In terms of formal policies regarding parental leave, twothirds (67%) of PDs reported having a formal maternity leave policy. Less than half (48%) of PDs reported having a paternity leave policy. (In the survey, the colloquial term paternity leave was defined as leave taken by the nonchildbearing parent, also referred to as secondary caregiver leave, and is used interchangeably here for linguistic simplicity). Regardless of the existence of formal policies, most PDs (58%) reported that residents who give birth
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are typically provided with 6 weeks of maternity leave (Fig. 1). The most common length of leave for the nonchildbearing parent is either 1 (45%) or 2 (27%) weeks. University-based programs are more likely to have policies in place for the non-child bearing parent (59% vs 33%, p ¼ 0.044). Larger programs are more likely to have such leave policies: 72% of programs with more than 6 residents had a formal paternity leave policy, while only 40% of programs with 6 or fewer residents had one (p ¼ 0.05). Larger programs also make arrangements for leave more frequently (p ¼ 0.001). Program size is not significantly associated with the presence of maternity leave policies or the length of maternity or paternity leave provided. Qualitative interviews revealed that issues surrounding breastfeeding and childcare are common stressors for residents with children. Residents interviewed emphasized the personal importance of providing their infants with breast milk given long work hours and time away from their child, but expressed difficulty in finding time to express breast milk during the workday. Five PDs (8%) reported having a formal policy regarding breastfeeding; however, 77% of PDs stated that a typical attending at their program would permit a resident to scrub out of a case to pump, 58% reported the availability of lactation facilities in their hospitals. Programs located in the Northeast are less likely to have lactation spaces available than in other parts of the country (29%, vs 71% for all other regions, p ¼ 0.037). Arranging childcare was identified as a significant challenge. Although 14% of PDs were unaware of their residents’ childcare arrangements, others reported that most residents’ children were either in daycare (32%) or cared for by a stay-at-home spouse (27%) or nanny (14%). Thirty-eight percent of PDs reported the presence of on-site childcare at their hospitals. In qualitative interviews, residents expressed frustration with limited availability of slots at on-site childcare centers and with daycare drop-off and pick-up times that were incompatible with their daily schedule. Interviews also revealed that, to the extent possible, residents attempt to plan for a “convenient” time during residency to have a child. Program directors were asked when the best time during residency for a trainee to have a child is. Among university PDs, 46% said that the lab years are the best time to have a child during residency; 52% of independent residency PDs said that no particular time during residency is best. Overall, 15% of PDs say they would advise against having a child during residency. In qualitative interviews, residents who were parents recalled feeling apprehensive about how they would be viewed. Residents who had become pregnant expressed concerns about “being a burden on colleagues,” “being
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Figure 1. Typical length of parental leave provided for residents. (A) Maternity leave length, in weeks. (B) Paternity leave length, in weeks. Responses to survey question, “How much time are residents typically allotted for [maternity/paternity] leave?” Regardless of the existence of formal policies, most program directors (58%) reported that residents who give birth are allotted 6 weeks of maternity leave. Paternity leave was most commonly reported as 1 (45%) or 2 (27%) weeks.
perceived as lazy” or “not carrying my weight,” and “being treated differently than my peers.” Male residents described guilt at leaving their teams shorthanded while on paternity leave, saying, “the good residents take as little time as possible.” When asked about the effects of parenthood on residents, 61% of PDs reported that becoming a parent negatively affects female trainees’ work, including by placing an increased burden on fellow residents (33%), as well as negatively affecting scholarly activities (9%), clinical activities (8%), dedication to patient care (6%), and timeliness (5%) (Fig. 2). Program directors were significantly less likely to say that becoming a parent negatively affects male trainees’ work (34% vs 61%, p ¼ 0.003). Similarly, respondents perceived children as decreasing female residents’ well-being more often than male residents’ (32% vs 9%, p < 0.001) (Fig. 3).
DISCUSSION As the demographics of surgical practice evolve, it is imperative to understand the role that pregnancy and parenthood play among surgical trainees. Despite parenthood being common among surgical trainees, there is a lack of consistency across programs nationwide in the existence of parental leave policies after the birth of a child, and variability in the length of maternity and paternity leave provided. Beyond the post-partum period, these results demonstrate inconsistency in the availability of onsite childcare and the ability to continue breastfeeding, which requires access to lactation facilities and break time to express breast milk. These findings are also notable for the program director perception that becoming a parent more negatively affects the training and well-being of female residents.
Figure 2. Program director attitudes regarding negative effects of parenthood on residents’ work, stratified by resident sex. Responses to survey question, “Beyond [maternity/paternity] leave, in what way does having a baby most negatively affect the work of a [female/male] trainee?” Program directors were significantly more likely to report that becoming a parent negatively affects female trainees’ work in 1 of 5 dimensions than male trainees’ work (61% vs 34%, p ¼ 0.003).
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Figure 3. Program director attitudes regarding the impact of parenthood on resident well-being, stratified by resident sex. Responses to survey question, “How much do you think having children affects a [male/female] resident’s well-being during training?” Thirty-two percent of program directors reported that children decrease female residents’ well-being vs 9% for male residents (p < 0.001).
The changing demographics of the surgical workforce make these issues timely. In 2014, 41% of general surgery residents were female, while 48% of medical school matriculants were women.4,5 These issues are not only relevant to the growing number of women joining the surgical profession. Studies show that fathers today are more involved in parenting than at any time in the recent past.6 Changing societal and gender norms have resulted in more dual-earner professional families and greater expectations that men are active and involved parents. Residents of both sexes expressed in qualitative interviews that time away from their children and inability to contribute equally to the work of parenting contributed to feelings of guilt and conflict with their partners. Furthermore, families with parents of the same sex require careful consideration of the traditional terminology of maternity and paternity. For the purpose of linguistic simplicity, the traditional terminology was used in this manuscript, but the authors fully acknowledge the limitations and potential bias associated with this taxonomy. With ongoing societal changes including the recent Supreme Court Ruling on Obergefell v. Hodges, making same-sex marriage legal in the US, nontraditional parenting situations requiring new and thoughtfully crafted solutions may arise. In this regard, program directors will need to remain open to addressing the evolving family needs of their trainees. These findings are also relevant to discussions around maintaining the future surgical workforce and the recruitment of talented medical students. Studies of specialty selection among medical students have demonstrated that students perceive surgical careers to pose challenges to raising children.7 Furthermore, lifestyle factors play into both specialty choice and the 20% attrition rate among
surgical residents.7-9 Talented students may opt out of pursuing surgery because they wish to be parents and view surgical training as incompatible with pregnancy and childrearing. Although just 15% of program directors surveyed said they would advise a trainee not to have a child during residency, it is possible that subtle discouragement occurs in other ways. A single institution survey of post-match fourth year medical students reported that 90% were asked potentially discriminatory questions during residency interviews, including being asked their marital status and whether they had children. Of the students applying to surgical residencies, 50% were asked about plans for pregnancy, while only 14% of nonsurgical applicants were asked (p ¼ 0.057).10 It is important to view these findings in the context of other medical specialties. As early as 1989, the American College of Physicians published a position paper urging internal medicine programs to create written policies on parental leave.11 A 2007 survey of pediatrics programs showed that 90% had maternity leave policies in place.12 Obstetrics and gynecology is a specialty with a high proportion of female trainees and a demanding schedule. A 2001 survey of these residency programs revealed that 80% and 69% had maternity and paternity leave policies, respectively, and it is reasonable to speculate that these rates have since increased.13 We encourage surgical residency programs without leave policies in place to consider creating guidelines that are compatible with their program and appropriate to their residents’ needs. Doing so may reduce the apprehension that residents feel in addressing these needs, and allow for predictability in planning for parental leave. Moreover, the existence of such guidelines is relevant to
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the recruitment of future trainees. Students should be able to know, in advance of matching at a program, whether their basic needs will be met in the event of becoming a parent. Such guidelines will allow applicants to rank programs based on educational goals rather than lifestyle needs. We further encourage residency programs to be attentive to the well-being of their trainees who are parents. In the 2008 National Study of Expectations and Attitudes of Residents in Surgery (NEARS), residents with children reported higher levels of strain on their family life relative to married residents without children.7 Parental leave after the birth of a child is only 1 component of the many stressors trainees face in parenting during residency. Longer-term issues, such as access to childcare and the option to continue breastfeeding, are key. Just 38% of PDs report the availability of on-site childcare. Where on-site daycare is available, residents may face waiting lists to enroll, and pick up and drop off times that are incompatible with their work schedules. Residents in qualitative interviews spoke specifically about the need for their spouses to make career sacrifices to comport with daycare schedules, and their frustrations with long waiting lists for on-site care. Where possible, programs may wish to leverage their institutions to provide resources like childcare subsidies, backup care in the event of a child’s illness, or after-hours care.14 The American Academy of Pediatrics15 recommends that infants be exclusively fed breast milk for the first 6 months of life and that breastfeeding continue until at least 1 year of age. Residents identified the inability to meet their own goals for breastfeeding to be a significant source of stress and disappointment. The Affordable Care Act (ACA)16 requires employers to provide lactation facilities and break time to pump; however, less than 60% of PDs reported the availability of lactation spaces in their hospitals. Although most PDs reported that a typical attending would permit a resident to scrub out of a case to pump, residents may not feel empowered to make such a request, though delays in expressing breast milk can result in pain, leakage, infection, and decrease in milk supply. Programs may wish to work with their hospitals to ensure compliance with Affordable Care Act provisions, and to explicitly offer break time for breastfeeding residents to pump if patient care permits. A notable finding of this survey is the program director perception that parenthood more negatively affects women’s well-being. Undoubtedly, pregnancy and birth place a greater physical burden on women, and studies of pregnant physicians have shown rates of pregnancy complications similar to those in women who work other
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physically demanding jobs, including increased risk of preterm delivery and pre-eclampsia.17 However, beyond the duration of pregnancy and maternity leave, this becomes a multidimensional issue. The NEARS study demonstrated that male surgical residents were actually more likely to report satisfaction with their work if they were married or had children, and that marriage served to increase both confidence and happiness at work.7 Women, by contrast, expressed feeling overwhelmed after giving birth, and reported concerns about their reputation at work after simply getting married.18 The findings described here should be considered in light of the limitations of self-reported surveys. Despite the assurance of strict anonymity, program directors may have chosen their responses to avoid expressing controversial opinions or placing their residency program in an unflattering light. Further, the surveyed sample of program directors (26% of PDs nationwide) may not be representative of the total population of PDs. This sample is over-representative of both female PDs (30%, vs 16% nationwide) and programs with a large proportion of female residents (nationally, 40% of general surgery residents are women, but here, 64% of PDs reported that more than 40% of their residents were female). It is unclear in which way these factors may have biased the results.
CONCLUSIONS The length and rigor of surgical residency is necessary to train skilled surgeons, particularly in the setting of limitations on duty hours. A move toward competency-based education, rather than strict quotas of weeks worked, may provide additional flexibility for residents. However, the suggestions offered above would improve parenting trainees’ quality of life and continue to attract talented students into the field without sacrificing educational rigor. Overall, PD reports indicated a lack of uniformity in surgical residency policies regarding parental leave, as well as inconsistency in access to childcare and availability of lactation facilities. Notably, PDs perceived parenthood to more negatively affect the training and well-being of female residents. These findings are relevant to the recruitment of surgical residents and maintenance of the future surgical workforce. We encourage program directors to be attentive to the well-being of trainees who are parents and, where possible, work to improve availability of childcare and lactation facilities. Programs without leave policies in place may wish to create formal guidelines to ensure predictability for their trainees.
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Author Contributions Study conception and design: Sandler, Tackett, Longo, Yoo Acquisition of data: Sandler, Tackett Analysis and interpretation of data: Sandler, Tackett, Yoo Drafting of manuscript: Sandler, Tackett, Yoo Critical revision: Sandler, Tackett, Longo, Yoo
16. Patient Protection and Affordable Care Act. 42 USC x 18001 et seq (2010). 17. Finch SJ. Pregnancy during residency: a literature review. Acad Med 2003;78:418e428. 18. Chen MM, Yeo HL, Roman SA, et al. Life events during surgical residency have different effects on women and men over time. Surgery 2013;154:162e170.
REFERENCES 1. Livingston G. For most highly educated women, motherhood doesn’t start until the 30s. Washington, DC. Available at: http://www.pewresearch.org/fact-tank/2015/01/15/for-mosthighly-educated-women-motherhood-doesnt-start-until-the-30s/. Accessed July 6, 2015. 2. Troppmann KM, Palis BE, Goodnight JE Jr, et al. Women surgeons in the new millennium. Arch Surg 2009;144:635e642. 3. Dillman DA, Smyth JD, Christian LM. Internet, Mail, and Mixed-Mode Surveys: The Tailored Design Method. 3rd ed. Hoboken: Wiley; 2009. 4. AAMC. Number of active residents by type of medical school graduation, GME specialty, and gender. Washington, DC. Available at: https://www.aamc.org/data/421322/tableb2.html. Accessed July 7, 2015. 5. AAMC. U.S. medical school applications and matriculants by school, state of legal residence, and sex. Washington, DC: 2014. Available at: https://www.aamc.org/download/321442/ data/factstable1.pdf. Accessed July 7, 2015. 6. Parker K, Wang W. Roles of moms and dads converge as they balance work and family. Washington, DC. Available at: http:// www.pewsocialtrends.org/2013/03/14/modern-parenthood-rolesof-moms-and-dads-converge-as-they-balance-work-and-family/. Accessed July 7, 2015. 7. Sullivan MC, Yeo H, Roman SA, et al. Striving for work-life balance: effect of marriage and children on the experience of 4402 US general surgery residents. Ann Surg 2013;257:571e576. 8. Yeo H, Bucholz E, Ann Sosa J, et al. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg 2010;252:529e534; discussion 534e536. 9. Brown EG, Galante JM, Keller BA, et al. Pregnancyrelated attrition in general surgery. JAMA Surg 2014;149: 893e897. 10. Santen SA, Davis KR, Brady DW, Hemphill RR. Potentially discriminatory questions during residency interviews: frequency and effects on residents’ ranking of programs in the national resident matching program. J Grad Med Educ 2010;2: 336e340. 11. Parental leave for residents. American College of Physicians. Ann Int Med 1989;111:1035e1038. 12. McPhillips HA, Burke AE, Sheppard K, et al. Toward creating family-friendly work environments in pediatrics: baseline data from pediatric department chairs and pediatric program directors. Pediatrics 2007;119:e596ee602. 13. Davis JL, Baillie S, Hodgson CS, et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol 2001;98:1093e1098. 14. Key LL Jr. Child care supplementation: aid for residents and advantages for residency programs. J Pediatrics 2008;153: 449e450. 15. Breastfeeding and the use of human milk. Pediatrics 2012;129: e827ee841.
Invited Commentary James F Whiting, Portland, ME
MD, FACS
Dr Sandler and colleagues report on a survey of program directors conducted to ascertain attitudes and policies around pregnancy and child rearing during surgical residency. The study was well constructed, with uncommon thought and effort given to its design. It was administered and reviewed by the Association of Program Directors in Surgery (APDS) research committee, a system designed to highlight surveys of exceptional value to all of us experiencing “survey fatigue”; then it was distributed online. The results paint a clear picture of the current state of surgical residencies, and the conclusions and discussion are illuminating and important. Only 1 thing is missing: Where is the outrage? Only 26% of program directors chose to complete this survey, despite it arriving with the imprimateur of the APDS research committee. Of those who did complete it, only 38% of programs reported providing childcare options. A little more than half provided lactation facilities, and incredible as it may seem, in an era in which an individual’s every thought and action in a modern residency feel like they must be documented, fully one-third of programs did not even have a policy on maternity leave. This is shameful, and it is all of our shared responsibility to change it. Warren Buffett is famously reported to have attributed a portion of his investing success to the fact that he was only competing against half of the population. Is this what we want for surgery? If we want to encourage the best and the brightest to enter our field, we need to be leaders in creating opportunities for women in surgery, not stragglers grudgingly giving in to societal pressures. Maternity leave policies, lactation facilities, and childcare are the lowest of low hanging fruit. The availability of childcare may be rare in most training programs, but look at the 12 health care organizations that made it into Fortune magazine’s top 100 workplaces in 2015. Ten of those 12 organizations offer childcare and most of them subsidize it. All of them provide lactation facilities and all of them have detailed and generous policies around maternity leave.