Clay illustration by Lily Offit; Photographed by Ben Denzer
May M. Kyaw [1], Angela Pham [1], Gaia Linfield [2], Zoe Burger [2], Sara Toulouie [3], and Olivia Yang [4]
[1] David Geffen School of Medicine at UCLA
[2] University of California, San Francisco School of Medicine
[3] California Northstate University College of Medicine
[4] California University of Science and Medicine, School of Medicine
Correspondence should be addressed to May M. Kyaw, Angela Pham, Gaia Linfield, Zoe Burger, Sara Toulouie, and Olivia Yang at mmkyaw@mednet.ucla.edu; angelapham@mednet.ucla.edu; gaia.linfield@ucsf.edu; zcburger@health.ucsd.edu; sara.toulouie6181@cnsu.edu; yango@calmedu.org
BACKGROUND
Since 2017, women have comprised the majority of enrolled U.S. medical students, marking a milestone in the gradual diversification of America’s next generation of physicians [1]. We represent six of these female medical students from schools across California. As members of the American College of Physicians California Council of Student Members Women in Medicine Committee, we aim to identify and address unique challenges female physicians and trainees face in the career of medicine while advocating for their equity in well-being, compensation, and career advancements.
As the number of women in medicine increases, so does the number of women starting families during their graduate medical education (GME) years. Approximately 40% of women plan to have a child during their GME training [2]. However, there is a concerning absence of consistent, standardized parental leave policies across GME programs.
By reviewing the importance of parental leave policies for the health and well-being of residents, we offer our unique perspectives and recommendations as female medical students to members of the Accreditation Council for Graduate Medical Education (ACGME). We challenge fellow medical students and physicians-in-training to strongly consider parental leave policies as influential components in one’s decision-making process for residency programs. Although we focus on maternity leave policies, we believe that all new parents be afforded the same protection. Family leave policies should be inclusive of all parents and primary caretakers, including gender non-binary and transgender individuals as well as non-biological parents.
FEDERAL, AMA, AND ABMS POLICIES
The United States is the only industrialized country that does not mandate paid parental leave for all employees [3,4]. The Family and Medical Leave Act (FMLA) of 1993 is the legal framework for understanding federal parental leave requirements. The FMLA entitles individuals who have worked at least 1250 hours in the past 12 months to take up to 12 weeks of unpaid, jobprotected leave for family and medical reasons— including the birth of a child. In the 2011 Supreme Court ruling of Mayo Foundation v. the United States, the Court recognized medical residents as fulltime employees, officially recognizing that residents should be allowed the same benefits as others who work more than forty hours a week [5]. However, medical residents in their first year of training who have less than 12 months of full-time work are not protected under FMLA.
There have been recent efforts to advocate for more flexible parental leave policies for physicians-in-training. Following a report by the ACGME Council of Review Committee Residents in June 2019, the American Board of Medical Specialties (ABMS) convened a task force composed of a multidisciplinary team of physicians to reform the policy on parental leave for residents. The new “ABMS Policy on Parental, Caregiver and Family Leave,” effective July 2021, requires all ABMS Member Boards with training programs of two or more years to offer a minimum of six weeks off, at least once, during training for parental, caregiver, and medical leave, without exhausting vacation time or sick leave and without requiring an extension in training [6]. The policy does not supersede existing institution or program policies that meet the minimum requirements set forth by ABMS; for example, the American Board of Obstetrics and Gynecology allows for residents to take up to 24 weeks of leave over their entire residency duration. However, one potential shortcoming of the ABMS policy is that it only applies to physicians in training programs of two or more years and does not cover subspecialty programs that may last only one year, such as those in addiction medicine, hospice and palliative medicine, and geriatric medicine. Additionally, because the policy only applies to those who are working toward an initial certification in a specialty or subspecialty, it does not cover physicians who have completed their residency or fellowship training.
This progressive new policy is a promising and encouraging step in the right direction. However, new parents may continue to face barriers rooted in the culture of an institution and competing interests of different stakeholders. For instance, funding incentives may stand at odds with providing paid leave time to residents. Similarly, program directors concerned with ensuring that education goals are met may be reluctant to allow for time off without extension of training. Additional barriers include ensuring there is adequate coverage of services while a resident is on leave.
RESEARCH FINDINGS & SIGNIFICANCE
A 2019 study surveying 844 physician mothers found that only half were offered paid maternity leave, with the other half using sick leave or accrued paid time off. Most respondents reported wanting a longer time off, closer to the 12 weeks stipulated by the FMLA. Many of those surveyed limited their maternity leave due to facing discrimination for taking time off, being verbally pressured to return, feeling compelled to resume their clinical duties, and feeling threatened to make up time lost through extra call or clinic time [7].
The average length of maternity leave across 15 residency programs was found to be 6.6 weeks [8]. Policies on maternity leave vary across specialties: 90% of pediatric residencies, 88% of radiology residencies, and only 67% of general surgery programs have specified, formal family leave policies [9]. One post-partum study found that about 75% of surveyed surgical residents perceived the duration of their leave to be inadequate, and one-third of respondents reported strongly considering leaving residency altogether [10].
The adverse effects of inadequate protected leave time are far-reaching. Residents have higher rates of adverse pregnancy-related conditions, including preeclampsia, preterm labor, and intrauterine growth restriction [11,12]. Many physician mothers stop breastfeeding earlier than desired because of limited time to breast pump, poor access to lactation facilities, and workplace discrimination [7]. Additionally, decreased skin-to-skin contact time between a mother and her newborn may negatively impact baby bonding and hinder the baby’s social development, while increasing the risk of postpartum depression for the mother [13].
Maternity leave also financially impacts the employer. Although economic research specific to maternity leave in health systems is limited, research in other industries suggests that paid parental leave generates cost savings for businesses due to reduced turnover of the workforce [14]. Given that highly skilled workers, such as physicians and residents, are not readily renewable resources, they are costly to replace [14]. A transparent, comprehensive maternity leave policy that allows for safe and healthy parenthood will not only increase savings for hospital systems decreasing recruiting efforts but also reduce burnout.
OPINION
As female students on the cusps of our medical careers, it is disheartening to see the lack of consistency among residencies’ parental leave programs. It is nothing short of distressing to think that a profession built on the protection and preservation of life, health, and well-being has still not adequately addressed the fundamental challenges that women face as mothers in medicine. The “ABMS Policy on Parental, Caregiver, and Family Leave” is certainly an exciting, progressive step in the right direction, but it does not adequately address the financial burden that women face when taking unpaid time off. Additional improvements can be made to add comprehensive protection for women who are planning to have children during their training.
Amidst the numerous challenges that we face in our medical training, many female medical students may feel that a lack of universal support for maternity leave limits their career ambitions and influences the choices made throughout the course of their medical training. In a 2019 survey conducted at Harvard Medical School, there was no significant gender difference in intention to pursue surgery, with both men and women reporting high rates of verbal discouragement from pursuing a surgical career. However, there was a statistically significant difference between how men and women perceived reasons of verbal discouragement: women were significantly more likely to perceive that it was based on their gender, age, and family aspirations [15]. Female medical students were also significantly more likely to report concerns about finding time for maternity leave and for being too old after residency to have children when considering a career in surgery [15]. Additionally, five different surgeon mothers in a 2019 New York Times article carefully laid out the struggles and barriers of choosing a career that they loved with discouragement from the people around them, while having to maintain a balance act in their roles as mothers and doctors [16].
As medical students, we are taught to care for the physical, mental, and emotional well-being of our patients. When we become medical trainees and providers, it will be our honor and privilege to use those teachings to care for the sick with utmost empathy and compassion. However, not providing female residents who have aspirations for both their career and family the basic support they need compromises the three facets of healthcare that we are charged with upholding – put simply, not providing compassionate and comprehensive maternity leave policies is antithetical to the core tenets of medicine. Physicians sacrifice much of their time caring for their patients yet are often disregarded when taking paid time off to care for their own loved ones [17]. A profession built on the protection and preservation of life, health, and well-being should adequately address the fundamental challenges residents face as new mothers. As advocates for gender equality in medical education, we ask for recognition by the medical community. We all deserve an equitable stance in our future career, unhampered by the stress of not receiving the support we need.
RECOMMENDATIONS AND CONCLUSION
We would like to strongly encourage the ACGME and program directors of residencies and fellowships to accomplish six feasible goals for birthing parents and primary caregivers. We hope attending and resident physicians understand that physicians in training should be allotted the following for the mental, emotional, and physical health of themselves and their families. Some of these goals are our own and some have been partially adapted from others [9,18,19].
We recommend:
All graduate medical institutions adopt a standard, paid 6-week minimum maternity leave for both birthing and non-birthing parents, as per the guidelines of the American Academy of Pediatrics as well as the American College of Obstetrics and Gynecology [20,21], that is separate from vacation or sick leave and that would not require extension of training.
Following the 6 weeks of paid leave, residents have flexibility in choosing options that best suit their mental and physical health and family needs. Residents may choose to:
Add up to 6 weeks of unpaid leave time with discussion to make up training hours lost during this additional unpaid leave
Start paid work from home with flexible research, electives, and/or telehealth visits
Return to full-time, inperson paid work
Maternity leave policies are inclusive of all trainees, including interns, regardless of their time spent at the institution.
24-hour calls are prohibited during the 3rd trimester for pregnant residents.
Program directors engage in monthly wellness check-ins with physicians-in-training and invite conversations regarding family life, to dismantle stigma regarding parental leave.
Institutions support trainees in childcare options, such as daycares on hospital campuses and established parental support groups amongst residency cohorts.
Further research to address the parental leave protections and benefits of nonbirthing and non-primary caregiver parents.
Female trainees and providers overcome many obstacles to become the healthcare providers that they are today. They should not have to sacrifice their own health and that of their family to abide by policies that do not protect those who are welcoming new lives into their family. There should be more regulations that protect our mental and physical health, from the beginning of our training to when we ourselves become the next generation's physicians and educators. In the meantime, we encourage conversations via committee and advocacy groups to amplify the current conversation, help raise awareness, and push for comprehensive maternity leave policies during residency.
POTENTIAL CONFLICTS OF INTEREST:
None.
REFERENCES
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