- Email: [email protected]
Pregnancy, parenthood, and family leave during residency
EDUCATION/RESIDENTS’ PERSPECTIVE
Matthew R. Lewin, MD, PhD Section Editor University of California San Francisco– Fresno Emergency Medicine Residency Program Fresno, CA
Pregnancy, Parenthood, and Family Leave During Residency
BACKGROUND
[Ann Emerg Med. 2003;41:568-573.]
INTRODUCTION
Copyright © 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1067/mem.2003.127
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This article addresses issues surrounding pregnancy, parenthood, and family leave during residency. Although emergency medicine resident schedules may be uniquely flexible compared with those of their counterparts in other specialties, domestic challenges facing emergency medicine residents are similar to those faced by all residents, regardless of specialty. There is a paucity of emergency medicine literature on the subject, and organizations such as the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) have surprisingly superficial policy statements regarding the issue of pregnancy, parenthood, and family leave during residency training. Although researchers in the fields of family medicine, psychiatry, and pediatrics have contributed much to our understanding and opinions regarding residents and their families during training,1-3 emergency medicine organizations and researchers lag far behind.
The number of female applicants to US medical schools has risen dramatically since Dr. Elizabeth Blackwell became the first woman graduate in 1849.4,5 Between 1990 and 2000, the percentage of female medical students matriculating into US medical schools has increased from approximately 30% to more than 40%.6,7 Similarly, the number of female residents and faculty has increased in all fields of medicine, including emergency medicine. As of 1999, approximately 20% of emergency physicians were women, and more than 30% of these female emergency physicians were younger than 35 years old.8 In 2001, 28% of applicants matching in emergency medicine were women.9 Thus, there has been a large influx of young, female emergency physicians into the specialty in recent years. Between the start of medical school and the end of residency or fellowship, men and women are likely to face the challenge of finding partners and starting families. Although about 90% of male physicians marry, only about 70% of female physicians marry. Of these, almost 90% will marry professional men and of these, nearly 50% will be dual-physician marriages.1,10,11 Women in professional marriages
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typically take primary responsibility for child rearing and management of domestic issues.3,12 Furthermore, women in dual-physician marriages are more likely to subjugate their careers in an effort to promote family well-being.3,6,13 Although the optimal time for parenthood, logistically and psychologically, may be after completion of residency,12 the pressures of increasing age and fertility are a reality for female physicians. More than half have their first child during residency training,2,14 although there is no literature to date that specifically addresses birth rates for female or male residents in emergency medicine during emergency medicine residency. A recent survey of teaching hospitals suggests that the average maternity leave is 6 weeks, whereas paternity leave varies widely, between 1 day and 7 weeks.15 POLICIES
In 1999, the ACEP board of directors approved a policy statement entitled, “Family Leave of Absence,”16 which endorses the principle that the health and integrity of “working physicians’ parent/child/family relationships are essential to the physicians’ wellbeing.” Although this policy explicitly includes residents, it is exceptionally vague in terms of specifics. Neither the American Board of Emergency Physicians (ABEM) nor SAEM has an explicit policy statement, although SAEM has an active committee on issues related to women in emergency medicine. To date, the Emergency Medicine Residents’ Association (EMRA) has not published an official position on family leave during residency. The American Medical Association’s (AMA) policy H-420.961 recommends that residency programs establish written policies for mater-
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nity, family, and medical necessity leave.17 Additional provisions for adoption and foster care could be very important for gay and lesbian residents not planning to have their own children or for infertile couples seeking to adopt. The American Academy of Pediatrics (AAP)18 and the American Academy of Family Physicians (AAFP)19,20 have highly detailed and specific family leave policies for physicians training in these specialties. The AAFP family leave policy is notable for its inclusion of highly specific guidelines for paternity leave. Remarkably detailed and scholarly, the AAP’s 1995 policy explains the legal and ethical underpinnings of the statement and the practical and sociological rationale for the policy. The AAP clearly states why programs should have their own specific, written policies for residents considering family leave. “Program policies that are not written and do not clearly delineate program practices regarding parental leave are problematic because: (1) departmental policies are often unclear and confusing and, as a result, may cause considerable anxiety; (2) the resident expecting a child often faces resentment from colleagues for the extra work that prolonged absences entail; (3) absences not planned in advance adversely affect the work schedules of peers; (4) morale problems among residency groups may be exacerbated by strategies that are used to replace or to cover absent residents; and (5) inconsistencies in departmental policies within and among programs can cause discord.”18 Table 1, which is largely based on the AAP and AAFP policy guidelines, suggests a model by which US emergency medicine programs and organizations might develop equitable and effective parental leave policies.18
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Parental leave policies need to be in compliance with federal and state laws. Federal law entitles employees to a total of 12 weeks of unpaid leave every 12 months. Federal law also mandates that the employer continue health insurance benefits during this period.21 Individual program policies may vary significantly. For example, one such program tells its female surgery residents to “work full steam until you go into labor.”22 PRACTICAL C O N S I D E R AT I O N S F O R EMERGENCY MEDICINE RESIDENTS, PROGRAMS, AND APPLICANTS
Residency directors and departments should be well prepared to address issues surrounding maternity and family leave. Maternity and parenthood are a reality that every residency program and its director and chief residents must face. The age of matriculation into residency programs is rising, and this will increase the number of difficult conceptions and higher-risk pregnancies. Residents may have a higher risk of preeclampsia than the general population, but the rates of miscarriage and neonatal morbidity and mortality are probably no different.13,23 One large study of female residents found that they are more likely to voluntarily terminate a pregnancy than the sexual partners of their male counterparts.24 The reasons for this were found to be multifactorial and included the influence of pregnancy and child rearing on career planning, finances, and personal and professional satisfaction. Women of advanced maternal age may not reveal that they are pregnant because they fear that they will not be able to carry the pregnancy to term and do not wish others to know
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until they feel the pregnancy has a good prognosis. Secrecy about a pregnancy can cause confusion and conflict because the rotation schedule of an entire residency class may require drastic rearrangement on short notice. It is probable that the
smallest residency programs experience the greatest logistical and psychological effect when a resident takes sick or family leave. Mothers may wish to nurse for many months beyond this leave of absence. Thus, programs should be
Table 1.
Suggested components of a comprehensive, resident-specific, family leave policy. Recommendation
Comment
1. Conform to the federal Family and Medical Leave Federal law entitles employees to a total of 12 Act and state laws. weeks unpaid leave each 12 months. Federal law mandates that the employer continue health insurance benefits during this period.21 2. Pregnant residents, expectant fathers, and those This is necessary to optimize schedule rearrangeplanning to adopt must notify the program ment to coincide with vacations, electives, and director about anticipated additions to the family other off-service rotations and as a courtesy to as soon as pregnancy, adoption, or the welother residents whose schedules may be affected. coming of foster children is confirmed. 3. Duration of leave should be determined in conjunction with the pregnant resident and her physician.
The time off before and after the birth of the child should be considered. The condition of both the mother and child should determine this. Provisions to extend or shorten the time off should be made as needed.
4. The father should notify those who will cover his The category of leave credited (eg, sick, vacation, responsibilities as soon as the mother is in labor. parental, short-term) should be specified. Whether leave is paid or unpaid should be specified. 5. Primary caregivers, male or female, should be The AAP recommends that new parents who are guaranteed 2 months’ paid leave after the child’s not the primary caregiver be given up to 2 weeks’ birth or adoption or placement in foster care. paid leave. This time may be drawn from vacation or elective if extended beyond 2 weeks. 6. Members of nontraditional families should be given the same consideration as parents in traditional families 7. There should be no loss in training status if the leave has been ≤2 months.
ABEM requires 36 months of training. Three- and 4-year programs should have predetermined mechanisms by which resident schedules can be adjusted to accommodate family- and sickleave related interruptions in training.
8. Programs should have clear and consistent Program directors must give these residents a policies for make-up of absences exceeding 12 complete list of requirements to be completed in weeks. Residency program directors must notify order to retain board eligibility.27 Similarly, residents on leave if they are in danger of falling policies for “payback” to residents providing below minimal requirements for board eligibility. unexpected and extra coverage should be predetermined. These plans, whether determined by the residents or the program director, should be clear and consistent. 9. Resident and patient safety must be primary considerations.
This requires thought and planning (see #2). Rotations should be modified at the discretion of the program director and in conjunction with the recommendations of the pregnant resident’s physician.
10. Each program must determine the most effective Prospective residents should consider program and least costly approach to coverage during size and duration when choosing a program. parental leave. Smaller programs and 3-year programs may not offer the same flexibility as 4-year programs.
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prepared to designate a private, nonbathroom area for breast-milk pumping, which may be required 15 minutes every few hours. Fellow residents should be kept abreast of these arrangements and be able to provide coverage during these intermissions. In implementing these policies, it is important to consider other, nonphysician staff that also may be pregnant or nursing. Special privileges for physician staff may cause significant resentment. Thus, these policies should be coordinated with other staff supervisors when there is potential for conflict. Another area of potential confusion and conflict occurs when a university-based residency program is affiliated with a privately managed hospital. These public-private affiliations have become more common as private community hospitals buy county facilities affiliated with public universities. Whose family leave policy applies to the resident? Some universities have agreements with private hospitals that resident affairs will be guided by the university residency policy rather than the private hospital’s. This situation is common and, suffice to say, contractual arrangements are often complex because differing policies apply by state and institution. Medical students who have families or are planning to start families should consider program size, length (3 versus 4 years), flexibility, maternity and family leave policies, and the facilities in which they will train. Fouryear programs tend to have more elective time and more time available for residents to compensate for time lost unexpectedly. Nevertheless, residents should be expected to complete the same core requirements as all other residents, especially in the emergency department. It is illegal for interviewers to ask prospective residents specific ques-
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tions about pregnancy and family planning. However, it is probably not an uncommon occurrence. Most interviewers are volunteers and may be unaware of the laws regarding discrimination during the interview process. During the course of an interview, it is natural to discuss family issues. However, this may put the applicant in an uncomfortable position. Applicants may feel anxious, and they may feel compelled to lie about their plans to start a family or bear children during residency for fear of prejudice by the residency program director or members of the selection committee. I believe this type of questioning is probably more likely to affect women than men, although I am not aware of any specific literature to substantiate this speculation. The laws specifying what an interviewer may or may not ask can be found in the Equal Employment Opportunity Act.25 An interviewer may decide to solicit open-ended responses by asking, “tell me about your family.” This is probably legal, and further questioning should be nonthreatening in order to leave discussion of personal matters to the discretion of the applicant. Interviewers should be prepared if an applicant decides to ask about a program’s family leave policy. Once this personal subject has been broached, the extent to which an interviewer can legally ask follow-up questions is complex. It is prudent to review this with the hospital’s legal department or others familiar with labor and discrimination issues before the interview season.
tions than their single or childless counterparts. Unfortunately, the complications of parenthood are more likely to spill over to their colleagues than are the personal issues of single or childless residents. Insistence on favorable schedules and summer vacations may become wellsprings of hostility between residents with children and those without. Are pregnant residents and new parents more likely to call in sick on account of sick infants and children, placing a burden on fellow residents? There is no literature to suggest one way or the other. However, other studies have strongly suggested that pregnant residents are more likely to be placed on bedrest for high-risk pregnancy than the general population.23 Because faculty do not typically provide sick-call coverage for residents, the remaining residents must pick up the slack in the schedule. It is natural for these situations to arise, and it is understandable that childless residents may feel putupon. In general, residents on paid leave are not strictly required by law to make up or “repay” time out during sick leave. However, many programs have departmental “payback” policies or a minimum number of shifts required for graduation. Covering residents are generally not protected from being pulled from electives or being assigned additional shifts. By the same token, there will not likely ever be a convenient time for a new parent to repay time taken from other residents. RESOURCES FOR RESIDENTS
C O N S I D E R AT I O N F O R CHILDLESS RESIDENTS AND SICK-CALL COVERAGE
New and established parents generally have more complex family situa-
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The American Association of Medical Colleges and the AMA are excellent resources for family planning and education for medical students and residents planning careers in
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any field of medicine. Iserson’s book26 is also excellent and has an entire chapter devoted to family issues. Many hospitals have on-site child care, which may be important for prospective residents as they contemplate different programs. A short list of helpful Web sites and publications is found in Table 2. In summary, the demographics of emergency medicine are changing, and institutional and departmental policies regarding maternity and family leave need to evolve accordingly. Prospective residents with or expecting children during residency, program directors, parents, and childless residents are best served if departmental and institutional policies are clear before an announcement of pregnancy is made. It is imperative that training programs be clear about expectations for cooperation and conduct by pregnant residents and their childless colleagues during periods of potential and anticipated leave. Emergency medicine differs from most other specialties because working hours are welldefined by the shift schedule. Because we are in the relatively unique position of having shifts rather than clinic or inpatient duties while on service, we have more flexibility in scheduling than most other types of residency programs. For example, residents in the same class can generally trade shifts to accommodate their personal needs within the scope of program and Residency Review Committee regulations. In contrast, it would be impractical and compromise patient care if family practice residents randomly switched duty in their continuity clinics. There is ample room for developing cohesive national and programspecific guidelines to accommodate residents in the process of having and raising children. There is also ample room for research. Despite the
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RESIDENTS’ PERSPECTIVE
issues being fairly well-defined, there has been virtually no research on the subject of maternity and parenthood in the emergency medicine literature. I was surprised that I could not find even one article in the English literature about postpartum depression among residents in any field of medicine, let alone emergency medicine. There is clearly a need for uniform family leave policies in individual
emergency medicine programs and probably on the national level as well. Residents in family practice and pediatrics have national policies that guide individual programs to develop their own policies in concordance with the Residency Review Committee requirements for promotion to the next postgraduate year or graduation from residency. All residents need to know what missed work needs to be made up and what does not. Without
Table 2.
Resources for residents seeking information on selected aspects of family leave. Resource
Comment
Association of American Medical Colleges (AAMC) Many books, resources, and publications related 2450 N. Street NW; Washington, DC 20037-1126; to medicine and parenting (eg, Young-Shumate 202-828-0400, fax 202-828-1125; et al2 has dozens of superb, general references http://www.aamc.org about pregnancy during residency and psychological aspects of pregnancy during residency). American Academy of Family Physicians (AAFP) 11400 Tomahawk Creek Parkway, Suite 440, Leawood, KS 66211; 913-906-6000, fax 913-906-6095; E-mail [email protected];. http://www.aafpfoundation.org
Highly specific guidelines for both maternity and paternity leave. Multiple publications relating to child care and balancing work and family (eg, Parental Leave During Residency Training19)
American Academy of Pediatrics (AAP) 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098; 847-434-4000, fax 847-434-8000; E-mail [email protected]; http://www.aap.org
Everything from a new mother’s guide to breastfeeding to finding the best day care for your child.
American Medical Women’s Association (AMWA) Largest US women’s physician organization, dedi801 N. Fairfax Street, Suite 400, cated to issues specific to woman physicians and Alexandria, VA 22314; patients. Publisher of the Journal of the American 703-838-0500, fax 703-549-3864; Medical Women’s Association. Special issues of E-mail [email protected]; the journal have been dedicated to maternity and http://www.amwa-doc.org; medical practice.28 Gender Equity Hotline 703-838-0500 American Medical Association (AMA) 515 N. State Street, Chicago, IL 60610; 312-464-5000; http://www.ama-assn.org
Largest physician’s organization in the United States. Immense Web site with hundreds of links to relevant publications and resources related to physicians and their families.
FREIDA Online http://www.ama-assn.org/ama/pub/category/ 2997.html
Interactive database published by the AMA. Useful statistics and references relevant to residents and their families. Direct link to main AMA Web site.
Horizons http://www.ama-assn.org/ama/pub/category/ 2178.html
Horizons is a quarterly AMA Alliance newsletter for and by spouses of resident physicians and medical students. The publication is free and provides tips on how to handle the pressures of a medical marriage and raising children during and after residency.
Women Physicians Congress (WPC) http://www.ama-assn.org/ama/pub/category/ 172.html
Also part of the AMA, the WPC focuses on addressing women’s health and professional issues. Has resident representative on Board.
clearly defined policies, numerous questions remain unanswered. Is trading or moving shifts around equivalent to sick time off? Many family leave policies are combined with sick leave policies. It should be no surprise to hear residents ask whether a missed workday that must be made up is truly a “sick day.” Does a resident actually have maternity leave, or is she working the same amount as all the other residents but just on different days? How many working hours can a resident miss without having to extend the duration of residency training? Of course, these types of questions by a new parent will naturally cause resentment among those who have been pulled from their electives to cover for the sick or pregnant resident. A life-altering event such as the birth or adoption of a child requires greater than normal cooperation and flexibility between the new parent resident and his or her classmates. Thus, mutual understanding by classmates is essential for the smooth transition everyone must make when there is a new member of the ED’s extended family. I thank Elizabeth Muckerman, MD, for her helpful perspectives, and Herbert Bivins, MD, Michael Callaham, MD, Amy Kaji, MD, Marsha Lee, MD, and my mother for their helpful comments and perspectives. Reprints not available from the author. Address for correspondence: Matthew R. Lewin, MD, PhD, Department of Emergency Medicine, University of California San Francisco–Fresno, 445 South Cedar Avenue, Fresno, CA 93702; 559-459-5105, fax 559-4593844; E-mail [email protected].
REFERENCES 1. Tesch BJ, Osborne J, Simpson DE, et al. Women physicians in dual-physician relationships compared with those in other dual-career relationships. Acad Med. 1992;67:542-544. 2. Young-Shumate L, Kramer T, Beresin E. Pregnancy
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RESIDENTS’ PERSPECTIVE during graduate medical training. Acad Med. 1993;68:792-798.
spouse is a physician, too? J Am Med Womens Assoc. 1993;48:175-181.
Family practice residents’ maternity leave experiences and benefits. Fam Med. 1995;27:512-518.
3. Potee RA, Gerber AJ, Ickovics RJ. Medicine and motherhood: shifting trends among female physicians from 1922 to 1999. Acad Med. 1999;74:911-919.
12. Cujec B, Oancia T, Bohm C, et al. Career and parenting satisfaction among medical students, residents and physician teachers at a Canadian medical school. CMAJ. 2000;162:637-640.
21. Family Medical Leave Act, 1993 CDFS-1378-95.
4. Link EP. Elizabeth Blackwell, citizen and humanitarian. Woman Physician. 1971;26:451-458. 5. Krug K. Women ovulate, men spermate: Elizabeth Blackwell as a feminist physiologist. J Hist Sex. 1996;7:51-72. 6. Cydulka RK, D’Onofrio G, Schneider S, et al. Women in academic emergency. Acad Emerg Med. 2000;7:999-1007. 7. American Medical Association. Physician Characteristics and Distribution 2000-2001. Chicago, IL: American Medical Association; 2001. 8. Association of American Medical Colleges, US Medical School Faculty 1997. Faculty Roster System. Washington, DC: Association of American Medical Colleges; 1997. 9. NRMP-Match 2001. Available at: http://www. ama-assn.org/vapp/freida/spcstsc.0,2654,110,00.html. Accessed February 20, 2003. 10. Sobecks NW, Justice AC, Hinze S, et al. When doctors marry doctors: a survey exploring the professional and family lives of young physicians. Ann Intern Med. 1999;130:312-319. 11. Brotherton SE, LeBailly SA. The effect of family on the work lives of married physicians: what if the
13. Houry DE, Shockley LW, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med. 2000;35:394-397. 14. Sayres M, Wyshak G, Denterlain G, et al. Pregnancy during residency. N Engl J Med. 1986;314:418-423. 15. Philibert I, Bickel J. Maternity and parental leave policies at COTH hospitals: an update. Acad Med. 1995;70:1055-1058. 16. American College of Emergency Physicians. Family leave of absence. Ann Emerg Med. 2000;35:209-210. 17. American Medical Association. Education— policies for maternity, family and medical necessity leave for residents and employed physicians. Policy H-420.961. Chicago, IL: American Medical Association; 1991. 18. Policy Statement. Parental leave for residents and pediatric training programs (RE9540). Pediatrics. 1995;96:972-973. 19. American Academy of Family Physicians Web site. Parental Leave During Residency Training. Available at: http://www.aafp.org/x6959.xml. Accessed February 20, 2003. 20. Gjerdingen DK, Chaloner KM, Vanderscoff JA.
22. Carty SE, Colson LY, Garvey LS, et al. Maternity policy and practice during surgery residency: how we do it. Surgery. 2002;132:682-688. 23. Klebanoff MA, Shiono PH, Rhoads GG. Outcomes of pregnancy in a national sample of resident physicians. N Engl J Med. 1990;323:1040-1045. 24. Klebanoff MA, Shiono PH, Rhoads GG. Spontaneous and induced abortion among resident physicians. JAMA. 1991;265:2821-2825. 25. Equal Employment Opportunity Commission. Enforcement guidance on pre-employment disabilityrelated inquiries. Washington, DC: US Government Printing Office; 1994. 26. Iserson KV. Iserson’s Getting Into a Residency: A Guide for Medical Students. 5th ed. Tucson, AZ: Galen Press; 2000:334-339. 27. Report of the Council on Medical Education. Policies for maternal, family and medical necessity leave for resident and employed physicians. (Resolution 307, A-97). Available at: http://www.ama-assn. org/meetings/public/annual98/reports/cme/cmerpt6.htm. Accessed February 20, 2003. 28. Lenhart SA. Physician mothers: a conceptual model for planning and coping with motherhood and medical practice. J Am Med Womens Assoc. 1992;47:87-91.
Call for Resident Papers Annals of Emergency Medicine The “Residents’ Perspective” is soliciting ideas from emergency medicine residents for future articles. If you have an idea, an issue, or an experience about which you would like to write, submit an abstract (limit 250 words, doublespaced) outlining your idea. Give the names of your coauthors, if any. If your idea is chosen, you will be asked to write an article for the “Residents’ Perspective” section. Submit your abstract to Matthew R. Lewin, MD, PhD, Resident Fellow, Annals of Emergency Medicine, 1125 Executive Circle, Irving, TX 75038-2522. E-mail: [email protected].
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Matthew R. Lewin, MD, PhD Section Editor University of California San Francisco– Fresno Emergency Medicine Residency Program Fresno, CA
Pregnancy, Parenthood, and Family Leave During Residency
BACKGROUND
[Ann Emerg Med. 2003;41:568-573.]
INTRODUCTION
Copyright © 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1067/mem.2003.127
5 6 8
This article addresses issues surrounding pregnancy, parenthood, and family leave during residency. Although emergency medicine resident schedules may be uniquely flexible compared with those of their counterparts in other specialties, domestic challenges facing emergency medicine residents are similar to those faced by all residents, regardless of specialty. There is a paucity of emergency medicine literature on the subject, and organizations such as the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) have surprisingly superficial policy statements regarding the issue of pregnancy, parenthood, and family leave during residency training. Although researchers in the fields of family medicine, psychiatry, and pediatrics have contributed much to our understanding and opinions regarding residents and their families during training,1-3 emergency medicine organizations and researchers lag far behind.
The number of female applicants to US medical schools has risen dramatically since Dr. Elizabeth Blackwell became the first woman graduate in 1849.4,5 Between 1990 and 2000, the percentage of female medical students matriculating into US medical schools has increased from approximately 30% to more than 40%.6,7 Similarly, the number of female residents and faculty has increased in all fields of medicine, including emergency medicine. As of 1999, approximately 20% of emergency physicians were women, and more than 30% of these female emergency physicians were younger than 35 years old.8 In 2001, 28% of applicants matching in emergency medicine were women.9 Thus, there has been a large influx of young, female emergency physicians into the specialty in recent years. Between the start of medical school and the end of residency or fellowship, men and women are likely to face the challenge of finding partners and starting families. Although about 90% of male physicians marry, only about 70% of female physicians marry. Of these, almost 90% will marry professional men and of these, nearly 50% will be dual-physician marriages.1,10,11 Women in professional marriages
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RESIDENTS’ PERSPECTIVE
typically take primary responsibility for child rearing and management of domestic issues.3,12 Furthermore, women in dual-physician marriages are more likely to subjugate their careers in an effort to promote family well-being.3,6,13 Although the optimal time for parenthood, logistically and psychologically, may be after completion of residency,12 the pressures of increasing age and fertility are a reality for female physicians. More than half have their first child during residency training,2,14 although there is no literature to date that specifically addresses birth rates for female or male residents in emergency medicine during emergency medicine residency. A recent survey of teaching hospitals suggests that the average maternity leave is 6 weeks, whereas paternity leave varies widely, between 1 day and 7 weeks.15 POLICIES
In 1999, the ACEP board of directors approved a policy statement entitled, “Family Leave of Absence,”16 which endorses the principle that the health and integrity of “working physicians’ parent/child/family relationships are essential to the physicians’ wellbeing.” Although this policy explicitly includes residents, it is exceptionally vague in terms of specifics. Neither the American Board of Emergency Physicians (ABEM) nor SAEM has an explicit policy statement, although SAEM has an active committee on issues related to women in emergency medicine. To date, the Emergency Medicine Residents’ Association (EMRA) has not published an official position on family leave during residency. The American Medical Association’s (AMA) policy H-420.961 recommends that residency programs establish written policies for mater-
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nity, family, and medical necessity leave.17 Additional provisions for adoption and foster care could be very important for gay and lesbian residents not planning to have their own children or for infertile couples seeking to adopt. The American Academy of Pediatrics (AAP)18 and the American Academy of Family Physicians (AAFP)19,20 have highly detailed and specific family leave policies for physicians training in these specialties. The AAFP family leave policy is notable for its inclusion of highly specific guidelines for paternity leave. Remarkably detailed and scholarly, the AAP’s 1995 policy explains the legal and ethical underpinnings of the statement and the practical and sociological rationale for the policy. The AAP clearly states why programs should have their own specific, written policies for residents considering family leave. “Program policies that are not written and do not clearly delineate program practices regarding parental leave are problematic because: (1) departmental policies are often unclear and confusing and, as a result, may cause considerable anxiety; (2) the resident expecting a child often faces resentment from colleagues for the extra work that prolonged absences entail; (3) absences not planned in advance adversely affect the work schedules of peers; (4) morale problems among residency groups may be exacerbated by strategies that are used to replace or to cover absent residents; and (5) inconsistencies in departmental policies within and among programs can cause discord.”18 Table 1, which is largely based on the AAP and AAFP policy guidelines, suggests a model by which US emergency medicine programs and organizations might develop equitable and effective parental leave policies.18
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Parental leave policies need to be in compliance with federal and state laws. Federal law entitles employees to a total of 12 weeks of unpaid leave every 12 months. Federal law also mandates that the employer continue health insurance benefits during this period.21 Individual program policies may vary significantly. For example, one such program tells its female surgery residents to “work full steam until you go into labor.”22 PRACTICAL C O N S I D E R AT I O N S F O R EMERGENCY MEDICINE RESIDENTS, PROGRAMS, AND APPLICANTS
Residency directors and departments should be well prepared to address issues surrounding maternity and family leave. Maternity and parenthood are a reality that every residency program and its director and chief residents must face. The age of matriculation into residency programs is rising, and this will increase the number of difficult conceptions and higher-risk pregnancies. Residents may have a higher risk of preeclampsia than the general population, but the rates of miscarriage and neonatal morbidity and mortality are probably no different.13,23 One large study of female residents found that they are more likely to voluntarily terminate a pregnancy than the sexual partners of their male counterparts.24 The reasons for this were found to be multifactorial and included the influence of pregnancy and child rearing on career planning, finances, and personal and professional satisfaction. Women of advanced maternal age may not reveal that they are pregnant because they fear that they will not be able to carry the pregnancy to term and do not wish others to know
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RESIDENTS’ PERSPECTIVE
until they feel the pregnancy has a good prognosis. Secrecy about a pregnancy can cause confusion and conflict because the rotation schedule of an entire residency class may require drastic rearrangement on short notice. It is probable that the
smallest residency programs experience the greatest logistical and psychological effect when a resident takes sick or family leave. Mothers may wish to nurse for many months beyond this leave of absence. Thus, programs should be
Table 1.
Suggested components of a comprehensive, resident-specific, family leave policy. Recommendation
Comment
1. Conform to the federal Family and Medical Leave Federal law entitles employees to a total of 12 Act and state laws. weeks unpaid leave each 12 months. Federal law mandates that the employer continue health insurance benefits during this period.21 2. Pregnant residents, expectant fathers, and those This is necessary to optimize schedule rearrangeplanning to adopt must notify the program ment to coincide with vacations, electives, and director about anticipated additions to the family other off-service rotations and as a courtesy to as soon as pregnancy, adoption, or the welother residents whose schedules may be affected. coming of foster children is confirmed. 3. Duration of leave should be determined in conjunction with the pregnant resident and her physician.
The time off before and after the birth of the child should be considered. The condition of both the mother and child should determine this. Provisions to extend or shorten the time off should be made as needed.
4. The father should notify those who will cover his The category of leave credited (eg, sick, vacation, responsibilities as soon as the mother is in labor. parental, short-term) should be specified. Whether leave is paid or unpaid should be specified. 5. Primary caregivers, male or female, should be The AAP recommends that new parents who are guaranteed 2 months’ paid leave after the child’s not the primary caregiver be given up to 2 weeks’ birth or adoption or placement in foster care. paid leave. This time may be drawn from vacation or elective if extended beyond 2 weeks. 6. Members of nontraditional families should be given the same consideration as parents in traditional families 7. There should be no loss in training status if the leave has been ≤2 months.
ABEM requires 36 months of training. Three- and 4-year programs should have predetermined mechanisms by which resident schedules can be adjusted to accommodate family- and sickleave related interruptions in training.
8. Programs should have clear and consistent Program directors must give these residents a policies for make-up of absences exceeding 12 complete list of requirements to be completed in weeks. Residency program directors must notify order to retain board eligibility.27 Similarly, residents on leave if they are in danger of falling policies for “payback” to residents providing below minimal requirements for board eligibility. unexpected and extra coverage should be predetermined. These plans, whether determined by the residents or the program director, should be clear and consistent. 9. Resident and patient safety must be primary considerations.
This requires thought and planning (see #2). Rotations should be modified at the discretion of the program director and in conjunction with the recommendations of the pregnant resident’s physician.
10. Each program must determine the most effective Prospective residents should consider program and least costly approach to coverage during size and duration when choosing a program. parental leave. Smaller programs and 3-year programs may not offer the same flexibility as 4-year programs.
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prepared to designate a private, nonbathroom area for breast-milk pumping, which may be required 15 minutes every few hours. Fellow residents should be kept abreast of these arrangements and be able to provide coverage during these intermissions. In implementing these policies, it is important to consider other, nonphysician staff that also may be pregnant or nursing. Special privileges for physician staff may cause significant resentment. Thus, these policies should be coordinated with other staff supervisors when there is potential for conflict. Another area of potential confusion and conflict occurs when a university-based residency program is affiliated with a privately managed hospital. These public-private affiliations have become more common as private community hospitals buy county facilities affiliated with public universities. Whose family leave policy applies to the resident? Some universities have agreements with private hospitals that resident affairs will be guided by the university residency policy rather than the private hospital’s. This situation is common and, suffice to say, contractual arrangements are often complex because differing policies apply by state and institution. Medical students who have families or are planning to start families should consider program size, length (3 versus 4 years), flexibility, maternity and family leave policies, and the facilities in which they will train. Fouryear programs tend to have more elective time and more time available for residents to compensate for time lost unexpectedly. Nevertheless, residents should be expected to complete the same core requirements as all other residents, especially in the emergency department. It is illegal for interviewers to ask prospective residents specific ques-
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tions about pregnancy and family planning. However, it is probably not an uncommon occurrence. Most interviewers are volunteers and may be unaware of the laws regarding discrimination during the interview process. During the course of an interview, it is natural to discuss family issues. However, this may put the applicant in an uncomfortable position. Applicants may feel anxious, and they may feel compelled to lie about their plans to start a family or bear children during residency for fear of prejudice by the residency program director or members of the selection committee. I believe this type of questioning is probably more likely to affect women than men, although I am not aware of any specific literature to substantiate this speculation. The laws specifying what an interviewer may or may not ask can be found in the Equal Employment Opportunity Act.25 An interviewer may decide to solicit open-ended responses by asking, “tell me about your family.” This is probably legal, and further questioning should be nonthreatening in order to leave discussion of personal matters to the discretion of the applicant. Interviewers should be prepared if an applicant decides to ask about a program’s family leave policy. Once this personal subject has been broached, the extent to which an interviewer can legally ask follow-up questions is complex. It is prudent to review this with the hospital’s legal department or others familiar with labor and discrimination issues before the interview season.
tions than their single or childless counterparts. Unfortunately, the complications of parenthood are more likely to spill over to their colleagues than are the personal issues of single or childless residents. Insistence on favorable schedules and summer vacations may become wellsprings of hostility between residents with children and those without. Are pregnant residents and new parents more likely to call in sick on account of sick infants and children, placing a burden on fellow residents? There is no literature to suggest one way or the other. However, other studies have strongly suggested that pregnant residents are more likely to be placed on bedrest for high-risk pregnancy than the general population.23 Because faculty do not typically provide sick-call coverage for residents, the remaining residents must pick up the slack in the schedule. It is natural for these situations to arise, and it is understandable that childless residents may feel putupon. In general, residents on paid leave are not strictly required by law to make up or “repay” time out during sick leave. However, many programs have departmental “payback” policies or a minimum number of shifts required for graduation. Covering residents are generally not protected from being pulled from electives or being assigned additional shifts. By the same token, there will not likely ever be a convenient time for a new parent to repay time taken from other residents. RESOURCES FOR RESIDENTS
C O N S I D E R AT I O N F O R CHILDLESS RESIDENTS AND SICK-CALL COVERAGE
New and established parents generally have more complex family situa-
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The American Association of Medical Colleges and the AMA are excellent resources for family planning and education for medical students and residents planning careers in
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any field of medicine. Iserson’s book26 is also excellent and has an entire chapter devoted to family issues. Many hospitals have on-site child care, which may be important for prospective residents as they contemplate different programs. A short list of helpful Web sites and publications is found in Table 2. In summary, the demographics of emergency medicine are changing, and institutional and departmental policies regarding maternity and family leave need to evolve accordingly. Prospective residents with or expecting children during residency, program directors, parents, and childless residents are best served if departmental and institutional policies are clear before an announcement of pregnancy is made. It is imperative that training programs be clear about expectations for cooperation and conduct by pregnant residents and their childless colleagues during periods of potential and anticipated leave. Emergency medicine differs from most other specialties because working hours are welldefined by the shift schedule. Because we are in the relatively unique position of having shifts rather than clinic or inpatient duties while on service, we have more flexibility in scheduling than most other types of residency programs. For example, residents in the same class can generally trade shifts to accommodate their personal needs within the scope of program and Residency Review Committee regulations. In contrast, it would be impractical and compromise patient care if family practice residents randomly switched duty in their continuity clinics. There is ample room for developing cohesive national and programspecific guidelines to accommodate residents in the process of having and raising children. There is also ample room for research. Despite the
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issues being fairly well-defined, there has been virtually no research on the subject of maternity and parenthood in the emergency medicine literature. I was surprised that I could not find even one article in the English literature about postpartum depression among residents in any field of medicine, let alone emergency medicine. There is clearly a need for uniform family leave policies in individual
emergency medicine programs and probably on the national level as well. Residents in family practice and pediatrics have national policies that guide individual programs to develop their own policies in concordance with the Residency Review Committee requirements for promotion to the next postgraduate year or graduation from residency. All residents need to know what missed work needs to be made up and what does not. Without
Table 2.
Resources for residents seeking information on selected aspects of family leave. Resource
Comment
Association of American Medical Colleges (AAMC) Many books, resources, and publications related 2450 N. Street NW; Washington, DC 20037-1126; to medicine and parenting (eg, Young-Shumate 202-828-0400, fax 202-828-1125; et al2 has dozens of superb, general references http://www.aamc.org about pregnancy during residency and psychological aspects of pregnancy during residency). American Academy of Family Physicians (AAFP) 11400 Tomahawk Creek Parkway, Suite 440, Leawood, KS 66211; 913-906-6000, fax 913-906-6095; E-mail [email protected];. http://www.aafpfoundation.org
Highly specific guidelines for both maternity and paternity leave. Multiple publications relating to child care and balancing work and family (eg, Parental Leave During Residency Training19)
American Academy of Pediatrics (AAP) 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098; 847-434-4000, fax 847-434-8000; E-mail [email protected]; http://www.aap.org
Everything from a new mother’s guide to breastfeeding to finding the best day care for your child.
American Medical Women’s Association (AMWA) Largest US women’s physician organization, dedi801 N. Fairfax Street, Suite 400, cated to issues specific to woman physicians and Alexandria, VA 22314; patients. Publisher of the Journal of the American 703-838-0500, fax 703-549-3864; Medical Women’s Association. Special issues of E-mail [email protected]; the journal have been dedicated to maternity and http://www.amwa-doc.org; medical practice.28 Gender Equity Hotline 703-838-0500 American Medical Association (AMA) 515 N. State Street, Chicago, IL 60610; 312-464-5000; http://www.ama-assn.org
Largest physician’s organization in the United States. Immense Web site with hundreds of links to relevant publications and resources related to physicians and their families.
FREIDA Online http://www.ama-assn.org/ama/pub/category/ 2997.html
Interactive database published by the AMA. Useful statistics and references relevant to residents and their families. Direct link to main AMA Web site.
Horizons http://www.ama-assn.org/ama/pub/category/ 2178.html
Horizons is a quarterly AMA Alliance newsletter for and by spouses of resident physicians and medical students. The publication is free and provides tips on how to handle the pressures of a medical marriage and raising children during and after residency.
Women Physicians Congress (WPC) http://www.ama-assn.org/ama/pub/category/ 172.html
Also part of the AMA, the WPC focuses on addressing women’s health and professional issues. Has resident representative on Board.
clearly defined policies, numerous questions remain unanswered. Is trading or moving shifts around equivalent to sick time off? Many family leave policies are combined with sick leave policies. It should be no surprise to hear residents ask whether a missed workday that must be made up is truly a “sick day.” Does a resident actually have maternity leave, or is she working the same amount as all the other residents but just on different days? How many working hours can a resident miss without having to extend the duration of residency training? Of course, these types of questions by a new parent will naturally cause resentment among those who have been pulled from their electives to cover for the sick or pregnant resident. A life-altering event such as the birth or adoption of a child requires greater than normal cooperation and flexibility between the new parent resident and his or her classmates. Thus, mutual understanding by classmates is essential for the smooth transition everyone must make when there is a new member of the ED’s extended family. I thank Elizabeth Muckerman, MD, for her helpful perspectives, and Herbert Bivins, MD, Michael Callaham, MD, Amy Kaji, MD, Marsha Lee, MD, and my mother for their helpful comments and perspectives. Reprints not available from the author. Address for correspondence: Matthew R. Lewin, MD, PhD, Department of Emergency Medicine, University of California San Francisco–Fresno, 445 South Cedar Avenue, Fresno, CA 93702; 559-459-5105, fax 559-4593844; E-mail [email protected].
REFERENCES 1. Tesch BJ, Osborne J, Simpson DE, et al. Women physicians in dual-physician relationships compared with those in other dual-career relationships. Acad Med. 1992;67:542-544. 2. Young-Shumate L, Kramer T, Beresin E. Pregnancy
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RESIDENTS’ PERSPECTIVE during graduate medical training. Acad Med. 1993;68:792-798.
spouse is a physician, too? J Am Med Womens Assoc. 1993;48:175-181.
Family practice residents’ maternity leave experiences and benefits. Fam Med. 1995;27:512-518.
3. Potee RA, Gerber AJ, Ickovics RJ. Medicine and motherhood: shifting trends among female physicians from 1922 to 1999. Acad Med. 1999;74:911-919.
12. Cujec B, Oancia T, Bohm C, et al. Career and parenting satisfaction among medical students, residents and physician teachers at a Canadian medical school. CMAJ. 2000;162:637-640.
21. Family Medical Leave Act, 1993 CDFS-1378-95.
4. Link EP. Elizabeth Blackwell, citizen and humanitarian. Woman Physician. 1971;26:451-458. 5. Krug K. Women ovulate, men spermate: Elizabeth Blackwell as a feminist physiologist. J Hist Sex. 1996;7:51-72. 6. Cydulka RK, D’Onofrio G, Schneider S, et al. Women in academic emergency. Acad Emerg Med. 2000;7:999-1007. 7. American Medical Association. Physician Characteristics and Distribution 2000-2001. Chicago, IL: American Medical Association; 2001. 8. Association of American Medical Colleges, US Medical School Faculty 1997. Faculty Roster System. Washington, DC: Association of American Medical Colleges; 1997. 9. NRMP-Match 2001. Available at: http://www. ama-assn.org/vapp/freida/spcstsc.0,2654,110,00.html. Accessed February 20, 2003. 10. Sobecks NW, Justice AC, Hinze S, et al. When doctors marry doctors: a survey exploring the professional and family lives of young physicians. Ann Intern Med. 1999;130:312-319. 11. Brotherton SE, LeBailly SA. The effect of family on the work lives of married physicians: what if the
13. Houry DE, Shockley LW, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med. 2000;35:394-397. 14. Sayres M, Wyshak G, Denterlain G, et al. Pregnancy during residency. N Engl J Med. 1986;314:418-423. 15. Philibert I, Bickel J. Maternity and parental leave policies at COTH hospitals: an update. Acad Med. 1995;70:1055-1058. 16. American College of Emergency Physicians. Family leave of absence. Ann Emerg Med. 2000;35:209-210. 17. American Medical Association. Education— policies for maternity, family and medical necessity leave for residents and employed physicians. Policy H-420.961. Chicago, IL: American Medical Association; 1991. 18. Policy Statement. Parental leave for residents and pediatric training programs (RE9540). Pediatrics. 1995;96:972-973. 19. American Academy of Family Physicians Web site. Parental Leave During Residency Training. Available at: http://www.aafp.org/x6959.xml. Accessed February 20, 2003. 20. Gjerdingen DK, Chaloner KM, Vanderscoff JA.
22. Carty SE, Colson LY, Garvey LS, et al. Maternity policy and practice during surgery residency: how we do it. Surgery. 2002;132:682-688. 23. Klebanoff MA, Shiono PH, Rhoads GG. Outcomes of pregnancy in a national sample of resident physicians. N Engl J Med. 1990;323:1040-1045. 24. Klebanoff MA, Shiono PH, Rhoads GG. Spontaneous and induced abortion among resident physicians. JAMA. 1991;265:2821-2825. 25. Equal Employment Opportunity Commission. Enforcement guidance on pre-employment disabilityrelated inquiries. Washington, DC: US Government Printing Office; 1994. 26. Iserson KV. Iserson’s Getting Into a Residency: A Guide for Medical Students. 5th ed. Tucson, AZ: Galen Press; 2000:334-339. 27. Report of the Council on Medical Education. Policies for maternal, family and medical necessity leave for resident and employed physicians. (Resolution 307, A-97). Available at: http://www.ama-assn. org/meetings/public/annual98/reports/cme/cmerpt6.htm. Accessed February 20, 2003. 28. Lenhart SA. Physician mothers: a conceptual model for planning and coping with motherhood and medical practice. J Am Med Womens Assoc. 1992;47:87-91.
Call for Resident Papers Annals of Emergency Medicine The “Residents’ Perspective” is soliciting ideas from emergency medicine residents for future articles. If you have an idea, an issue, or an experience about which you would like to write, submit an abstract (limit 250 words, doublespaced) outlining your idea. Give the names of your coauthors, if any. If your idea is chosen, you will be asked to write an article for the “Residents’ Perspective” section. Submit your abstract to Matthew R. Lewin, MD, PhD, Resident Fellow, Annals of Emergency Medicine, 1125 Executive Circle, Irving, TX 75038-2522. E-mail: [email protected].
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