Perspectives of US General Surgery Program Directors on Cultural and Fiscal Barriers to Maternity Leave and Postpartum Support During Surgical Training | Medical Education and Training | JAMA Surgery | JAMA Network
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Table 1.  Demographic Characteristics of Program Directors
Demographic Characteristics of Program Directors
Table 2.  Residency Program Characteristics
Residency Program Characteristics
Table 3.  Representative Quotes for Each Theme
Representative Quotes for Each Theme
1.
Magudia  K, Ng  TSC, Bick  AG,  et al.  Parenting while in training: a comprehensive needs assessment of residents and fellows.   J Grad Med Educ. 2020;12(2):162-167. doi:10.4300/JGME-D-19-00563.1 PubMedGoogle ScholarCrossref
2.
Shanafelt  TD, Hasan  O, Dyrbye  LN,  et al.  Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.   Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023 PubMedGoogle ScholarCrossref
3.
Turner  PL, Lumpkins  K, Gabre  J, Lin  MJ, Liu  X, Terrin  M.  Pregnancy among women surgeons: trends over time.   Arch Surg. 2012;147(5):474-479. doi:10.1001/archsurg.2011.1693 PubMedGoogle ScholarCrossref
4.
Rangel  EL, Smink  DS, Castillo-Angeles  M,  et al.  Pregnancy and motherhood during surgical training.   JAMA Surg. 2018;153(7):644-652. doi:10.1001/jamasurg.2018.0153 PubMedGoogle ScholarCrossref
5.
American Board of Medical Specialties. Supporting early career physicians by collaborating with stakeholders. March 24, 2020. Accessed November 3, 2020. https://www.abms.org/news-events/supporting-early-career-physicians-by-collaborating-with-stakeholders/
6.
Palinkas  LA, Horwitz  SM, Green  CA, Wisdom  JP, Duan  N, Hoagwood  K.  Purposeful sampling for qualitative data collection and analysis in mixed method implementation research.   Adm Policy Ment Health. 2015;42(5):533-544. doi:10.1007/s10488-013-0528-y PubMedGoogle ScholarCrossref
7.
Sandelowski  M, Given  LM.  Theoretical Saturation: The Sage Encyclopedia of Qualitative Research Methods. Sage Publications; 2008.
8.
American Board of Surgery. Leave policy—general surgery. Updated October 2019. Accessed November 3, 2020. http://www.absurgery.org/default.jsp?policygsleave
9.
Altieri  MS, Salles  A, Bevilacqua  LA,  et al.  Perceptions of surgery residents about parental leave during training.   JAMA Surg. 2019;154(10):952-958. doi:10.1001/jamasurg.2019.2985 PubMedGoogle ScholarCrossref
10.
Humphries  LS, Lyon  S, Garza  R, Butz  DR, Lemelman  B, Park  JE.  Parental leave policies in graduate medical education: a systematic review.   Am J Surg. 2017;214(4):634-639. doi:10.1016/j.amjsurg.2017.06.023 PubMedGoogle ScholarCrossref
11.
Davids  JS, Scully  RE, Melnitchouk  N.  Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States.   J Am Coll Surg. 2017;225(3):411-418.e2. doi:10.1016/j.jamcollsurg.2017.05.018PubMedGoogle ScholarCrossref
12.
Kellogg  KC, Breen  E, Ferzoco  SJ, Zinner  MJ, Ashley  SW.  Resistance to change in surgical residency: an ethnographic study of work hours reform.   J Am Coll Surg. 2006;202(4):630-636. doi:10.1016/j.jamcollsurg.2005.11.024 PubMedGoogle ScholarCrossref
13.
Riall  TS.  Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the U.S.   Ann Surg. 2018;268(2):212-214. doi:10.1097/SLA.0000000000002779 PubMedGoogle ScholarCrossref
14.
Goffman  E.  Presentation of Self in Everyday Life. Doubleday; 1959.
15.
Bourdieu  P.  Outline of a Theory of Practice. Cambridge University Press; 1977. doi:10.1017/CBO9780511812507
16.
Rangel  EL, Castillo-Angeles  M, Changala  M, Haider  AH, Doherty  GM, Smink  DS.  Perspectives of pregnancy and motherhood among general surgery residents: a qualitative analysis.   Am J Surg. 2018;216(4):754-759. doi:10.1016/j.amjsurg.2018.07.036 PubMedGoogle ScholarCrossref
17.
Section on Medical Students, Residents, and Fellowship Trainees; Committee on Early Childhood.  Parental leave for residents and pediatric training programs.   Pediatrics. 2013;131(2):387-390. doi:10.1542/peds.2012-3542 PubMedGoogle ScholarCrossref
18.
Livingston-Rosanoff  D, Shubeck  SP, Kanters  AE, Dossett  LA, Minter  RM, Wilke  LG.  Got milk? design and implementation of a lactation support program for surgeons.   Ann Surg. 2019;270(1):31-32. doi:10.1097/SLA.0000000000003269 PubMedGoogle ScholarCrossref
19.
Choi  AMK, Moon  JE, Steinecke  A, Prescott  JE.  Developing a culture of mentorship to strengthen academic medical centers.   Acad Med. 2019;94(5):630-633. doi:10.1097/ACM.0000000000002498 PubMedGoogle ScholarCrossref
20.
Zhang  H, Isaac  A, Wright  ED, Alrajhi  Y, Seikaly  H.  Formal mentorship in a surgical residency training program: a prospective interventional study.   J Otolaryngol Head Neck Surg. 2017;46(1):13. doi:10.1186/s40463-017-0186-2 PubMedGoogle ScholarCrossref
21.
Dahlke  AR, Johnson  JK, Greenberg  CC,  et al.  Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the United States.   Ann Surg. 2018;268(2):204-211. doi:10.1097/SLA.0000000000002700 PubMedGoogle ScholarCrossref
22.
Ibarra  H, Ely  RJ, Kolb  DM. Women rising: the unseen barriers. Harvard Business Review. September 2013. Accessed November 15, 2020. https://hbr.org/2013/09/women-rising-the-unseen-barriers
23.
Zhuge  Y, Kaufman  J, Simeone  DM, Chen  H, Velazquez  OC.  Is there still a glass ceiling for women in academic surgery?   Ann Surg. 2011;253(4):637-643. doi:10.1097/SLA.0b013e3182111120 PubMedGoogle ScholarCrossref
24.
Skube  SJ, Arsoniadis  EG, Jahansouz  C, Novitsky  S, Chipman  JG.  Supplementing resident research funding through a partnership with local industry.   J Surg Educ. 2018;75(4):907-910. doi:10.1016/j.jsurg.2018.01.006 PubMedGoogle ScholarCrossref
25.
Association of American Medical Colleges. President’s budget includes major cuts to graduate medical education. February 11, 2016. Accessed November 15, 2020. https://www.aamc.org/advocacy-policy/washington-highlights/president-s-budget-includes-major-cuts-graduate-medical-education
26.
Ward  RC, Mainiero  MB.  Graduate medical education in the era of health care reform.   J Am Coll Radiol. 2013;10(9):708-712. doi:10.1016/j.jacr.2013.03.004 PubMedGoogle ScholarCrossref
27.
Clement  RC, Olsson  E, Katti  P, Esther  RJ.  Fringe benefits among US orthopedic residency programs vary considerably: a national survey.   HSS J. 2016;12(2):158-164. doi:10.1007/s11420-016-9494-8 PubMedGoogle ScholarCrossref
28.
Stefanidis  D, Miles  WS, Greene  FL.  Factors influencing residency choice of general surgery applicants—how important is the availability of a skills curriculum?   J Surg Educ. 2009;66(6):325-329. doi:10.1016/j.jsurg.2009.06.004 PubMedGoogle ScholarCrossref
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    Original Investigation
    May 19, 2021

    Perspectives of US General Surgery Program Directors on Cultural and Fiscal Barriers to Maternity Leave and Postpartum Support During Surgical Training

    Author Affiliations
    • 1Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
    • 3Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
    JAMA Surg. 2021;156(7):647-653. doi:10.1001/jamasurg.2021.1807
    Key Points

    Question  What is the perspective and experience of US surgical program directors regarding maternity leave and postpartum support?

    Findings  In this qualitative study of 40 surgical program directors, fiscal barriers and complex interpersonal and social issues within the surgical training culture were reported as obstacles to program directors providing support to pregnant residents.

    Meaning  The findings suggest that promotion of a surgical culture that normalizes pregnancy and motherhood during training is needed and that surgical program leadership should provide written maternity leave policies, defined lactation support, and structured mentorship and coaching programs.

    Abstract

    Importance  Although pregnancy during surgical residency is increasingly common, studies of surgical residents have identified challenges associated with pregnancy and motherhood. These include perceptions of different maternity leave policies among institutions, lack of mentorship, stigma, and desire for greater lactation support.

    Objective  To describe the perspective and experience of US surgical program directors regarding maternity leave and postpartum support for surgical residents.

    Design, Setting, and Participants  This qualitative study included surgical program directors of US general surgery residency programs who were selected using purposive-stratified, criterion-based sampling. Transcripts were collected from semi-structured interviews, which were audio-recorded and transcribed verbatim, from October 21, 2018, to June 1, 2019.

    Exposures  Maternity leave and postpartum support.

    Main Outcomes and Measures  Perspectives of program directors regarding maternity leave and postpartum support were categorized into common themes identified using content analysis.

    Results  A total of 40 US general surgical programs directors (28 [70.0%] male; mean [SD] age, 49.7 [6.8] years) were interviewed, of whom 36 (90.0%) were from university-based programs. All reported having maternity leave policies allowing a duration of leave of 6 weeks or longer. Analysis of program director interviews identified 5 themes: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of certain residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) resentment from coresidents who are asked to provide maternity leave coverage varies based on the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Complex interpersonal issues affected residents differently, including stigma, reluctance to change established surgical training patterns, and challenges with work-life balance.

    Conclusions and Relevance  This qualitative study found that sociopolitical issues within surgical training culture and fiscal constraints created obstacles against program directors supporting pregnant residents. These findings suggest that a multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and efforts by leadership to enforce family priorities is needed to promote a surgical culture that normalizes pregnancy and motherhood during training.

    Introduction

    Up to 50% of physicians plan to become parents during clinical training,1 a life event that has important implications for career development, work-life balance, and burnout.2 Studies of surgical resident perceptions on childbearing have described stigma and negative attitudes against parenthood, guilt over the burden placed on peers to cover leave, variable presence of maternity leave policies, a paucity of mentorship on balancing family priorities and work duties, and deficits in breastfeeding and childcare support.3,4 These difficulties may have negative implications for the surgical workforce, with nearly 40% of women who had a child during training reporting that they seriously considered leaving their training program and 30% reporting they would counsel a female medical student against a surgical profession owing to the challenges of becoming a mother during training.4

    The American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education (ACGME) convened at a cosponsored Parental Leave Workshop in February 2020 to discuss optimization of parental leave nationally, demonstrating a commitment of national stakeholders to improve family wellness for residents. Similarly, the American Board of Surgery (ABS) revised its leave policies to maximize flexibility for new parents and allow “surgical residents/fellows to exceed their professional goals without sacrificing their personal ones.”5 Despite recent focus on policy change and studies characterizing the concerns of surgical residents having children, information on the challenges that program directors face is needed to inform practical changes at the institutional level. The purpose of this study was to describe the perspectives of US program directors regarding maternity leave, pregnancy, and postpartum support during training to help provide the basis for building programmatic support for pregnant residents.

    Methods
    Study Design and Setting

    In this qualitative study, transcripts were collected from semi-structured interviews with US surgical program directors from October 21, 2018, to June 1, 2019. The institutional review board from the Partners Human Research Committee determined that this project met the criteria for exemption §45 CFR. Moreover, verbal informed consent was obtained from each participant at the beginning of their interview. This study followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.

    Participants

    To maximize diversity among participants and equal geographic distribution, purposive, stratified, criterion-based sampling was used to select program directors from the general surgery ACGME-accredited training programs throughout the US. This method emphasizes obtaining information-rich feedback from particularly knowledgeable or experienced individuals over probabilistic or random sampling.6 With criterion-based sampling, participants from all geographic regions and varied program sizes were sought to identify shared patterns and to understand how program directors have adapted to diverse conditions and training cultures. A description of the study and an invitation to participate in the interviews was electronically sent to potential participants. No participation incentive was offered.

    Interview Guide

    The interview guide was constructed using a comprehensive approach including a literature review and an expert panel. A preliminary conceptual framework was developed with a literature review to identify major themes related to maternity leave during residency training, with particular focus on surgical and procedural-based training programs. A primary interview guide was constructed using the most relevant themes, with open-ended questions tailored to program directors and narrowed to key questions through our consensus. The final interview guide included 15 questions focused on leave policies, obstacles faced by the program director in providing leave, perceived consequences of leave for a resident’s quality of work, and challenges in providing career guidance, lactation support, and childcare support for the pregnant resident. The guide was refined through a process of constant comparison as new themes and concepts arose from the interviews. This interview approach allowed flexibility to identify and explore topics not included in the original interview guide.

    Interview Procedures

    Program directors who responded to the initial invitation were contacted to set up a 30-minute interview. One of us (M.C.-A.) with advanced qualitative research training conducted all interviews from October 2018 to April 2019. After verbal informed consent, a period of 5 minutes was used to explain the study and answer questions, and the remaining time was used for the interview. Interviews were reviewed in real time to assess for new concepts and themes being discussed by each participant. All interviews were audio recorded with permission, transcribed verbatim, and evaluated shortly after completion to continuously update the interview guide and to assess for content saturation. Content saturation occurs when no new major concepts or ideas are being introduced during the interviews, ensuring that there are no unidentified ideas and that additional interviews are not likely to add substantially to the conceptual framework.7

    Statistical Analysis

    Descriptive statistics are reported using the mean for continuous variables and frequencies and percentages for categorical variables. Data were analyzed using qualitative content analysis, which facilitates interpretation of the content of text data through a systematic process of coding and identifying themes or patterns. Two of us (M.C.-A., E.L.R.) read all data repeatedly to achieve immersion and identify codes. Codes were discussed by us on several occasions, disagreements were resolved by consensus until 100% agreement was achieved, and a finalized codebook was built. Codes were sorted into categories or themes, and emergent themes were discussed among us to resolve any discrepancies. Illustrative quotations were identified for each theme. Thematic saturation was defined by the lack of new themes after 3 consecutive interviews. Atlas.ti 8 (Scientific Software Development, GmbH) software was used to organize the qualitative data.

    Results
    Participant and Program Characteristics

    Of 80 program directors invited to participate, 40 (50.0%) were interviewed, representing 40 of the 264 ACGME-accredited general surgery residency programs (15.2%). Of these participants, 28 (70.0%) were male, 36 (90.0%) were married, and 31 (77.5)% had at least 1 child, of which 25 (51.1%) were born outside of surgical training; the mean (SD) age was 49.7 (6.8) years. Mean (SD) time in the role of program director was 7.65 (5.13) years (Table 1).

    Most participants (36 [90.0%]) were from larger university-based programs with a mean (SD) of 6.67 (2.16) chief residents per program. All 4 regions of the country were represented, with the fewest programs from the South (6 [15.0%]). Most programs demonstrated sex parity in composition of residents, with 29 program directors (72.5%) reporting a proportion of female residents of 41% to 60%. However, in a substantial proportion of programs, a minority of residents were parents (0%-20% residents with children: 16 [40%]) (Table 2). All program directors reported having maternity leave policies allowing a duration of leave of 6 weeks or longer.

    Themes

    Five major themes emerged from the interviews: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of some residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) negative attitudes and resentment from coresidents asked to cover leave varies with the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Table 3 includes illustrative quotations for each described theme.

    Desire Not to Extend Training

    Although all program directors reported discussion of multiple leave options during resident orientation and again when their residents communicated their pregnancies, many described residents’ reluctance to lengthen leave by extending training. The recently revised ABS leave policy allows multiple options for time away from training including the ability to postpone completion by up to 8 weeks while remaining admissible to the certification process, extending training by up to 12 months, or adding an additional 2 weeks of leave up to 2 times during residency.8 However, most program directors reported little interest in these options based on pressure to start a fellowship on time, not wanting to be away while peers had to work, and reluctance to overlap training experiences with more junior residents.

    Consequences for Residents’ Quality of Work

    The program directors described marked variability in how childbearing affected residents’ quality of work, with many describing returning residents as conflicted and distracted. Faculty complaints about lower work quality and weak performance were reported to some program directors. Such feedback prompted 2 program directors to recommend extension of leave to the affected residents to reduce work-home conflict and improve subsequent performance. Conversely, other program directors reported that some residents returned more focused, thorough, organized, and detail oriented after returning from maternity leave.

    Lack of Formal Lactation Policies

    Program directors reported that faculty members were generally supportive of the need for nursing residents to step out of the operating room to pump milk. However, 2 common obstacles included residents’ discomfort in making the request and poor understanding by faculty of the practical logistics and time needed for the process. One program director described a situation in which an attending expected the resident to be back within 5 minutes even though she was not missing a critical portion of the procedure. The faculty did not seem to understand the time needed to express milk, highlighting the need for education. Program directors felt that such misunderstanding of residents’ personal needs compounded awkwardness and reluctance in making requests for accommodations. Creation of a written lactation policy was recommended to reduce trainee apprehension, provide clear guidelines describing resident needs, and set expectations for lactation breaks during cases.

    Resentment by Coresidents

    Program directors reported that some residents taking maternity leave experienced resentment from coresidents asked to cover their work. However, many reported that the way in which a resident was perceived before taking maternity leave was associated with the reaction of their coresidents. If the resident was viewed as a hard worker, requests for coverage would be met collaboratively. However, if the resident was previously perceived as weak, more animosity would result from shifting of clinical duties.

    Mismatch Between Leave Options and Financial Logistics

    Program directors reported that the lack of salary support limited the practicality of extended leave options. Few had resources, such as extra funding or workforce, to support all of the extended options permissible for residents by the ABS. In exceptional cases in which residents took a full year of leave, program directors were able to offer salary compensation by involving the resident in research and educational activities, but this option occurred rarely. However, most described difficulty providing remuneration to residents who decided to take more than 6 weeks of leave.

    Discussion

    The long duration of surgical training means that it coincides with the critical years of starting and raising a family. Recent focus on the challenges of female residents having children during training4,9-11 has galvanized efforts to create national mandates regarding family leave during training.5 This study reports perspectives of program directors and provides insight on the challenges of implementing changes at the institutional level, which include cultural and practical obstacles.

    Four of the 5 themes highlighted by this study demonstrate the need for culture change to normalize maternal and postpartum needs and cease the narrative that time away is equivalent to weakness. Traditional surgical resident identity is based on independence, grit, a strong work ethic that requires completion of tasks without assistance, and a commitment to the profession that avoids personal responsibilities that may interfere with hospital work.12,13 Sociologists have described the challenges of violating such traditional identities, with guilt on the part of those attempting change14 and disapproval by senior members of the hierarchy who protect the status quo.15 The former is described in a prior study16 that described fear of stigma deterring residents from requesting work accommodations despite health concerns during pregnancy or for the desired time off after the birth of a child. Hierarchy is well established in surgical training, with a paradigm that relies on support, guidance, and instruction from senior residents and faculty.12 Pressure to maintain this pyramidal structure forms a political barrier to residents asking for support. In the absence of written program policies limiting strenuous rotations close to term, outlining cross-coverage schedules, and defining lactation needs, pregnant or postpartum residents may be reluctant to approach more senior residents for coverage of clinical responsibilities. To avoid discord from inconsistencies in departmental policies, reduce anxiety for the expectant resident, and reduce resentment from colleagues asked to cover unplanned absences in an ad hoc fashion,17 policies for maternity leave and postpartum support should be transparent and openly disseminated.

    Similar to the obstacles that program directors experienced after ACGME work hour reductions, upcoming national mandates for parental leave present a paradigm shift and culture change that are likely to be met with resistance by both pregnant residents struggling to preserve their reputation and more senior members of the surgical team who trained under an older system. Such barriers to culture change were demonstrated by the illustrative quotes seen in this study, which include peer and faculty descriptions of new mothers as “weak,” “distracted,” or “dump[ing] on other residents.” Similar to interventions that facilitated the transition to reduced resident work hours,12 a top-down campaign by surgical leadership is needed to affirm and encourage time away from training to establish healthy behaviors and work-life balance, thereby establishing legitimacy for a surgeon’s identity that prioritizes family well-being. Initiatives with support and dissemination by the chair and program director, such as the formal lactation policy at the University of Michigan,18 highlight the needs of new parents, educate nonchildbearing faculty on the time requirements for pumping, and reduce barriers to implementation. Formal and informal communication from faculty and senior residents should be frequent and should enforce that becoming a parent is a celebratory event, time for parental bonding is an expectation and not reflective of a resident’s worth, and lactation in a postpartum woman is a basic body function that must be supported during the clinical work day.18

    We further call on training programs to adopt a culture of mentorship as a strategic priority by highlighting the measurable benefits, including increased career satisfaction, productivity, personal development,19 and decreased burnout.20 National studies4,21 of surgical residents have demonstrated that women are uniquely challenged to reconcile the dual roles of being a mother, partner, and surgeon. The demands of having and raising children while meeting the rigorous expectations of a surgical resident, such as long hours, maximizing educational opportunities, and obtaining sufficient operative experience, may contribute to higher rates of burnout and poor psychological well-being among women. Qualitative work suggests that like-gendered leadership and mentorship is associated with mitigating stress, increasing advocacy, and reducing feelings of disenfranchisement.21-23 At our institution, residents are asked to identify a “pregnancy mentor” from a list of faculty volunteers when they communicate their pregnancy to the program director. These volunteers are both mothers and surgeons and are committed to providing a coaching relationship, a safe setting to discuss challenges, and experience-based advice on balancing domestic and professional commitments. Although mentorship by leaders of a different sex are still encouraged, shared viewpoints with fellow surgeon mothers may increase the resident’s willingness to talk openly and address vulnerabilities without fear of judgment or misunderstanding. Such connections are important when discussing sensitive topics that can threaten identity and may help residents receive feedback in a constructive manner.

    The fifth theme identified addressed lack of funding to support longer maternity leave. Financial barriers to extramural opportunities are not unique in surgical training, with research efforts and resident benefits24 also constrained by high costs, limited grant funding, and graduate medical education resources threatened by Medicare spending cuts.25,26 With waning federal support, individual departments may bear greater costs internally for discretionary funding. Innovative solutions to maximize fiscal support should be tailored to institutional needs but may become increasingly important, as previous research suggests that medical students consider quality of life among the most important factors in selecting a program.27,28 As parenthood becomes more common during training,3,4 benefits, such as paid leave, may influence the decisions of the most competitive applicants.

    Limitations

    This study has several limitations. First, although efforts were made to capture a diverse sample, community and military programs were underrepresented, and viewpoints expressed may not reflect the experiences of these programs. Second, program directors from institutions with more experience with maternity leave or stronger benefit packages may have been more inclined to respond to our request for interviews, leading to response bias. Targeted efforts to evaluate smaller, community-based and independent programs may demonstrate additional needs. Third, it is not clear based on existing data how strongly culture change would improve wellness for residents having children during training. Although literature4 shows that the challenges of pregnancy and motherhood during residency contribute to professional dissatisfaction, caring for a new child and training to become a surgeon are inherently sleep-depriving, all-consuming endeavors that may be difficult to undertake simultaneously regardless of the support provided. Future research investigating burnout and wellness before and after implementation of programmatic changes would be helpful to better understand the direct impact of residency support. In addition, details of nonmonetary assistance to resident mothers, such as health plans and moonlighting opportunities, were not explored in this study and may impact overall financial strain and merit future research.

    Conclusions

    The findings of this qualitative study suggest that, despite increasing recognition of the need for more support for women having children during residency, sociopolitical issues within surgical training culture present obstacles. Surgical program directors reported complex interpersonal issues, including stigma, reluctance to change established surgical training patterns, and struggles with work-life balance that affected residents differently. A multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and iterative efforts by leadership to enforce family priorities appear to be necessary to promote a surgical culture that normalizes motherhood during surgical training.

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    Article Information

    Accepted for Publication: February 16, 2021.

    Published Online: May 19, 2021. doi:10.1001/jamasurg.2021.1807

    Corresponding Author: Erika L. Rangel, MD, MS, 1153 Centre St, Fourth Floor, Boston, MA 02130 (erangel@bwh.harvard.edu).

    Author Contributions: Drs Castillo-Angeles and Rangel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Castillo-Angeles, Rangel

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Castillo-Angeles, Rangel

    Administrative, technical, or material support: Rangel.

    Supervision: All authors.

    Conflict of Interest Disclosures: None reported.

    Meeting Presentation: This paper was presented at the Annual Clinical Congress of the American College of Surgeons; October 20, 2019; San Francisco, California.

    References
    1.
    Magudia  K, Ng  TSC, Bick  AG,  et al.  Parenting while in training: a comprehensive needs assessment of residents and fellows.   J Grad Med Educ. 2020;12(2):162-167. doi:10.4300/JGME-D-19-00563.1 PubMedGoogle ScholarCrossref
    2.
    Shanafelt  TD, Hasan  O, Dyrbye  LN,  et al.  Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.   Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023 PubMedGoogle ScholarCrossref
    3.
    Turner  PL, Lumpkins  K, Gabre  J, Lin  MJ, Liu  X, Terrin  M.  Pregnancy among women surgeons: trends over time.   Arch Surg. 2012;147(5):474-479. doi:10.1001/archsurg.2011.1693 PubMedGoogle ScholarCrossref
    4.
    Rangel  EL, Smink  DS, Castillo-Angeles  M,  et al.  Pregnancy and motherhood during surgical training.   JAMA Surg. 2018;153(7):644-652. doi:10.1001/jamasurg.2018.0153 PubMedGoogle ScholarCrossref
    5.
    American Board of Medical Specialties. Supporting early career physicians by collaborating with stakeholders. March 24, 2020. Accessed November 3, 2020. https://www.abms.org/news-events/supporting-early-career-physicians-by-collaborating-with-stakeholders/
    6.
    Palinkas  LA, Horwitz  SM, Green  CA, Wisdom  JP, Duan  N, Hoagwood  K.  Purposeful sampling for qualitative data collection and analysis in mixed method implementation research.   Adm Policy Ment Health. 2015;42(5):533-544. doi:10.1007/s10488-013-0528-y PubMedGoogle ScholarCrossref
    7.
    Sandelowski  M, Given  LM.  Theoretical Saturation: The Sage Encyclopedia of Qualitative Research Methods. Sage Publications; 2008.
    8.
    American Board of Surgery. Leave policy—general surgery. Updated October 2019. Accessed November 3, 2020. http://www.absurgery.org/default.jsp?policygsleave
    9.
    Altieri  MS, Salles  A, Bevilacqua  LA,  et al.  Perceptions of surgery residents about parental leave during training.   JAMA Surg. 2019;154(10):952-958. doi:10.1001/jamasurg.2019.2985 PubMedGoogle ScholarCrossref
    10.
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