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Medical News & Perspectives
March 4, 2020

Fixing the Parent Trap for Resident Physicians

JAMA. 2020;323(12):1119-1121. doi:10.1001/jama.2020.1084

Seeing residents struggle during their first several months after becoming a parent inspired Michael Gisondi, MD, to take action. As vice chair of education in the Department of Emergency Medicine at Stanford University’s School of Medicine, he teamed up in the fall of 2017 with the emergency medicine residency program’s then-chief resident, June Gordon, MD, to craft a new policy that would lessen the strain.

The fruit of their efforts was a return-to-work policy for all new parents, including those who had a child born into their family, used a surrogate, adopted, or fostered. Under the policy, new parents can choose to forgo overnight shifts, unscheduled call, or having more than 3 shifts in a row for 6 weeks after their return from parental leave. For 4 weeks before their estimated delivery date, pregnant residents are exempt from overnight shifts, unscheduled call, and more than 3 shifts in a row. The policy also covers parental leave, lactation, and a comprehensive list of other resources for new parents.

“This policy required a lot of very thoughtful conversation about what new parents really needed and what made a difference,” said Gordon, who surveyed parents in the program about the difficulties they faced. Gisondi and Gordon, who is now a fellow in critical care medicine at Stanford, worked with a task force of university stakeholders to develop the policy.

It has since become a template for other residency programs across the country. This grassroots effort reflects the growing recognition that all residents need clear and consistent policies to ease their burden after a new child arrives. Yet many of the 40% of residents who report that they plan to have a child during their training still find themselves navigating a confusing patchwork of policies that may vary from program to program or institution to institution.

“To be able to address the very real concerns of having gender equity in medicine, this is something that we have to address in a pragmatic and positive way,” Gisondi said.

The Third Rail

Less than half of the graduate medical education programs at 12 top medical schools have paid childbearing or family leave policies for residents, a 2018 study found. Yet all 15 programs in the study had those policies in place for faculty. This parental leave “have and have not” divide between faculty and residents is driven in part by academic medicine’s overreliance on residents to cover clinical care. When 1 resident takes leave during their program, it can lead to disruptions or a strain on the remaining residents, explained study coauthor Reshma Jagsi, MD, DPhil, director of the radiation oncology residency program at the University of Michigan in Ann Arbor.

Jagsi said it’s very important to have policies that enable both parents to take an active role in child-rearing to support equity in medical training. Seven of the programs she studied had parental leave policies in place for nonbirth parents, 1 specifically offered paternity leave, and 6 extended parental leave to adoptive parents or same-sex couples. Residents’ average paid maternity leave was 6.6 weeks and the average parental leave was 3.9 weeks.

“Not only do we disadvantage the one sex that bears children and lactates if we expect very, very short periods of leave from residency training, but we also perpetuate that myth that women should be the primary parent,” Jagsi said.

A 2019 survey of about 800 female residents found that most reported taking 6 weeks of maternity leave, cobbled together with vacation and sick time. “Maternity leave is clearly not a vacation,” said Shobha Stack, MD, PhD, lead author of the 2019 survey and assistant professor of medicine at the University of Washington in Seattle. “Imagine using your vacation time for maternity leave, then coming back to an 80-hour work week knowing you won’t have another week off for a year. That’s rough, especially when you are recovering from childbirth.”

The current, widely variable policies on maternity leave may be detrimental to both resident and child well-being, Stack said. Half of the mothers surveyed reported burnout, regardless of the duration of their leave. Women who took a maternity leave lasting more than 6 weeks were more likely to report feeling supported by their program’s administration and breastfeeding longer than women whose leave lasted 6 weeks or less.

When deciding how much maternity leave to take, the most important factor that women in the survey mentioned was not wanting to extend their training. Stack explained that extending training for even a few weeks can delay a physician’s ability to start a fellowship or take a full-time job.

Even schools that want to develop parental leave policies for residents may find it difficult to reconcile institutional requirements as well as specialty board and Accreditation Council for Graduate Medical Education (ACGME) rules. In fact, Gordon explained, Stanford’s task force found it to be a “third rail.”

“Each medical board has different requirements for training, and one broad institutional policy can't address all the nuances that are required within that,” Stack explained.

Misunderstandings about specialty board policies also occur. For example, the American Board of Internal Medicine (ABIM) Leave of Absence and Vacation policy allows residents up to 1 month of leave per year. The ABIM’s Deficits in Required Training Time policy permits residents another month of leave without extending their training if the resident is clinically competent when training ends.

But a survey of internal medicine residency directors found that only 4.3% understood that 1 month is defined in the policy as 5 weeks. In fact, 93.5% of program directors incorrectly reported that they would have to extend a resident’s leave if she took 4 weeks of vacation plus 8 weeks of leave. In the wake of the article, the ABIM updated its website to make the policy more clear.

“[I] think there were many women out there who had to unnecessarily extend training because people [misunderstood the policy],” said survey author Kathleen Finn, MD, senior associate program director for resident and faculty professional development at Massachusetts General Hospital's Internal Medicine Residency Program in Boston. She noted that the newly clarified policy helps all residents and gives program directors necessary flexibility. “If someone's family member is ill or their parent is dying, they need to go home and take care of them and we need to know what is allowed,” she said

“Absolutely, ACGME and ABMS [American Board of Medical Specialties] need to clarify policies and develop consistent recommendations for the leave that's allowed that takes into account the move towards assessing competency rather than simply time during training,” Jagsi said.

The ACGME enacted a policy in 2018 that requires graduate medical education programs to have a clear parental leave policy. But additional changes may be on the horizon, as the ABMS and ACGME had a joint workshop scheduled last month to assess current resident and fellow parental leave policies and identify potential improvements.

“[Parent-friendly scheduling] seems like a simple no-brainer for the next iteration of the common requirements,” Gisondi said. “This is a far simpler one to implement than many of the other work-hours restrictions and transitions of care expectations that have been implemented with the same goal.”

Paving the Way

In the meantime, residents, residency programs, and institutions are carving their own paths forward.

When a pregnant junior resident approached Sarah Shubeck, MD, MS, chief resident in the Department of Surgery at the University of Michigan, about wanting to breastfeed, Shubeck decided to develop a policy. “I did this to pave the way and make it a bit easier for someone coming after me as kind of a service to my former self, who was quiet and who struggled,” she said.

After her own maternity leave, Shubeck found there were lactation rooms available in the locker rooms, but they were often unavailable when she needed them. So, she asked that nursing mothers be given the right to commandeer call rooms during the day. A fridge and a comfortable chair were added, too.

“If we don't make it easy and accessible [to pump] and normal in our conversation, women will consistently choose to kind of avoid the pumping,” Shubeck said. She noted this can cause discomfort, mastitis, or even reduced milk supply, which can lead women to discontinue breastfeeding earlier than they had hoped.

The policy, which has since been emulated by several other programs, also enables residents to take breaks during long surgeries to pump. She noted that some can last 8 to 10 hours, and it’s unreasonable to expect a lactating mother to wait that long. Faculty agreed to strategize with residents to find a safe time during surgery when they can step out for 20 to 30 minutes to pump. The biggest change, Shubeck said, has not been the logistics but rather a cultural shift that recognizes lactation as a health need, not an extra break.

“It's recognizing that we should prioritize the health of our workforce in addition to the health of our patients,” she said.

As of July 1, ACGME will mandate that all programs have “clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care,” as part of its common program requirements. In preparation, Jennifer Best, MD, associate dean for graduate medical education at the University of Washington in Seattle, and her colleagues have surveyed the lactation facilities in each of the university’s 113 residency and fellowship programs. The survey has helped discover problems like difficulties finding rooms or rooms that lack a computer or Wi-Fi so residents can continue working while they pump.

“A lot of places think they have it covered, but when you start looking at the details and…how those rooms are situated, you're often not where you think you are,” she said.

The Indiana University School of Medicine’s emergency medicine residency program not only followed Stanford’s lead by implementing a scheduling policy last October, it went a step further. Pregnant residents automatically avoid night shifts during their first and third trimester, said Kimberly Chernoby, MD, JD, chief resident in the program.

Chernoby said she was motivated to develop the policy after reading a study showing an increased risk of miscarriage or preterm birth associated with working night shifts during pregnancy. She said it was important to making the scheduling change automatic to reduce the odds that a woman will feel guilty and decline the schedule change. Pregnant women may request night shifts, which some do because they may find it slower paced, she said.

“We're trying to encourage our colleagues across campus to adopt it and then trying to also encourage our faculty to adopt it,” Chernoby said.

Both Gisondi and Chernoby said their policies have received overwhelming support from both residents and faculty. Their programs have 35 to 40 residents, so little burden has fallen to other residents, they noted. But Gisondi said he thinks that smaller programs could tailor similar policies to their needs.

“I don’t think that there's any size program or specialty who couldn't do something to improve the quality of life of new parents,” he noted.

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