Parental Leave During Surgical Residency

On August 7, 2019, the article, "Perceptions of Surgery Residents About Parental Leave During Training" (Maria S. Altieri, Arghavan Salles, Lisa A. Bevilacqua, et al.), was published in JAMA Surgery.

Dr. Melanie Edwards describes the article findings, what they mean for the cardiothoracic surgery specialty, and her view on the topic of parental leave during surgical training.

Parental Leave During Surgical Residency

A surgical career, including cardiothoracic, has traditionally been considered incompatible with an engaged family life. In years past, the few women who braved the still male-dominated training environments either accepted that having a family was not an option or tried to do both with varying degrees of success. Male surgeons in this era were largely absentee spouses and parents. Attitudes are shifting, but the recent survey of surgery resident perceptions around parental leave and pregnancy by Altieri et al. published in JAMA Surgery highlights the ongoing concerns that arise when parental leave is taken in the clinical setting.  

Survey results
The 2,188 completed responses to the survey were distributed evenly between male and female residents with a large proportion of junior trainees (40% PGY 1 & 2), the majority of whom (71%) did not have children. While only 15% of residents in the survey had actually taken parental leave during clinical residency, nearly two-thirds had coresidents who had done so. Women most often took 4-6 weeks while male residents commonly took less than 2 weeks of parental leave. However, most residents thought maternity leave should be greater than 6 weeks and paternity leave 2-4 weeks.

Encouragingly, a majority of residents who took paternal leave felt extremely supported by other residents (43%) and faculty (40%) but one-third felt unsupported. Still, of the residents who took leave, a lack of universal policies across all American Council of Graduate Medical Education (ACGME) specialties was seen as the top obstacle. Residents who had not taken parental leave thought that the unreasonable strain on the residency program was of most concern. Few residents had knowledge of the actual American Board of Surgery (ABS) policies.

Current Policy and Recommendations
The American Board of Thoracic Surgery (ABTS) does not have a parental leave policy; however, residents must have 12 continuous months of training in the last year for board eligibility. The ABS has outlined a more comprehensive policy that allows some flexibility in training with advance approval where the 5 clinical years can be completed over 6 academic years for reasons that include family issues and maternity leave. The ACGME only mandates that residents be informed of parental leave policies during the interview process and in employment contracts. Interestingly, the American Academy of Pediatrics recommends a minimum of 6-8 weeks of parental leave irrespective of gender. 

In My View
Although the concept of parents taking time off to bond with a newborn child would seem to be a reasonable and straightforward expectation, parental leave can still be a major logistical challenge. Reasons for this vary, but as the idea of leave becomes more supported, the programmatic elements needed for training programs to accommodate leave without major disruptions lag behind. When programs lack depth of coverage or flexibility, this leads to the perception of undue strain on the residents and fellows covering the extra workload, and concerns on the part of those taking leave around having others pick up the slack and how they are perceived when they return to work. Additionally, residents contemplating having children often do not have models to follow or mentors to advise, as this problem extends into the surgical workplace.

Women face specific challenges in this regard. The peak child-bearing years coincide with the medical undergraduate and graduate years when having children can lead to delays in graduation, extend training, and complicate the transition to fellowship. Many choose to have children during research years, but this is not always an option. Delaying childbirth is not a better solution where the incidence of infertility and high-risk pregnancies increases. Neither is early career an optimal time for extended leave when surgeons are building clinical practices and may have fewer coverage options in small sub-specialty groups, or risk derailment of academic careers with missed leadership opportunities.

Women do not solely bear the negative effects of the conflict between career and family/personal life. Adherence to traditional gender roles means male residents and surgeons can be subjected to skepticism and even derision for taking parental leave. These are dangerous attitudes since the lack of family or personal engagement is a cause of burnout and can ultimately compromise surgeon performance, with far-reaching consequences for both the surgeon and the medical system.

Although the concept of parents taking time off to bond with a newborn child would seem to be a reasonable and straightforward expectation, parental leave can still be a major logistical challenge.

Melanie A. Edwards, MD

Where Do We Go From Here?
Culture change to increase the acceptance of parental leave for both genders is the first step. Traditional hierarchies need to be abandoned in managing the coverage gaps if advanced practice practitioner coverage is not sufficient. Well-defined, clearly communicated policies around parental leave can facilitate advance planning. There are no easy, simple, or foolproof solutions, but with creativity and flexibility, both on the part of residents and programs, parental leave can be seen as a joyful life event rather than a burden on the system. 

Melanie A. Edwards, MD, is a cardiothoracic surgeon at IHA Cardiovascular & Thoracic Surgery. She also holds positions on the STS Workforce on Evidence-Based Surgery, Workforce on National Databases, Workforce on Career Development, and Workforce on Diversity and Inclusion.