Feature

Taking Their Own Advice: Disparity in Paid Family Leave among Top Medical Schools

Debra Weinstein

Although pediatric medical organizations, including the American Academy of Pediatrics, have demanded congressional legislation to ensure that new parents receive 12 weeks of paid family leave — based on evidence of health benefits to the child — it appears that physicians are not following their own advice on the matter. According to recent JAMA findings, institution-wide policies providing paid family leave for residents were offered by only eight of 15 major medical institutions.

Debra Weinstein, MD, vice president of graduate medical education at Partners HealthCare and associate professor of medicine at Harvard Medical School, and colleagues, suggested that little information has been available on institution-level policies pertaining to paid family leave for residents. In the current study, the researchers reviewed 15 graduate medical education–sponsoring institutions affiliated with 12 medical schools.

The list of evaluated institutions mirrored a prior article that identified a cohort named to “top 10” lists based on research funding or academics. Weinstein and colleagues defined childbearing leave as absence taken by birth mothers; family leave as additional leave given to birth mothers, or to fathers or nonbirth parents with a new child; and maternity leave as encompassing both childbirth leave and designated family leave available to childbearing mothers.

 
Although pediatric medical organizations have demanded congressional legislation to ensure that new parents receive 12 weeks of paid family, many physicians are not following their own orders on the matter.
Source: Adobe

The researchers found that seven of the participating institutions provided a clear-cut policy on paid childbearing leave, with a mean duration of 5.7 weeks (range, 2-8 weeks). For maternity leave, the mean duration was 6.6 weeks (range, 2-10 weeks). In addition, seven institutions provided paid parental leave for nonbirth parents in their policies, with six of the seven including same-sex couples and adoptive parents, and one specifying “paternity” leave. Also among these seven institutions, 3.9 weeks (range, 1-8 weeks) of paid leave was reported.

Weinstein and colleagues noted that all 12 of the affiliated medical schools had policies providing paid parental leave for their faculty physicians. They added that the duration of paid leave for residents offered by all of the institutions was less than the 12 paid weeks currently endorsed by the American Academy of Pediatrics and the Pediatric Policy Council.

Healio Rheumatology spoke with Weinstein about the key findings of the study, the necessity of family leave at the societal level, and the dangers of over-working among health care professionals.

Q: Could you talk about the findings of your study?

Weinstein: We focused on parental leave policies currently in place for residents. Parenting during residency is particularly challenging. Residency training extends from 3 to as many as 7 years — often followed by subspecialty fellowship training. Residents and fellows work extremely long hours in very high stress jobs. They have often relocated for their training, and are geographically distant from their support systems. Many have significant educational debt: The average debt of graduating medical students is more than $180,000. So, as challenging as it is to be a new parent in any set of circumstances, it is particularly challenging for residents.

We were interested in looking at how different teaching hospitals handle parental leave. It is important to note that the Family Medical Leave Act, or FMLA, has provisions that allow up to 12 weeks of leave — but it doesn’t address salary continuation. We found that more than half of the institutions don’t have an institution-wide policy that guarantees paid leave.

We acknowledge that some hospitals without institution-level policies may be flexible and generous with policies or practices determined at the department or program level. However, there is a significant downside to this: it is hard for residents to make complicated family planning decision when they can’t identify a consistent leave policy and know in advance what they can count on. Also, residents should not have to disclose that they are considering having a child in order to get information about leave, and should not have to individually negotiate parental leave benefits.

Q: Could you offer some thoughts from the perspective of these institutions, whether they offer leave or not?

Weinstein: I believe that GME program leaders and teaching hospital executives are trying very hard to do the right thing and maximally support their trainees. But they face a variety of significant constraints — most notably the absolute imperative to ensure patient coverage in a context where teaching hospitals rely heavily on residents as caregivers. Residency programs have little redundancy with respect to patient care assignments, so resident absences are challenging.

Also, teaching hospitals usually face tight budget constraints — and covering absences with “moonlighters” or building intentional redundancy in staffing is expensive. There are also complicated issues to address in terms of fairness and/or equity among trainees, such as which activities need to be “made up” after a leave of absence, and whether coverage of one resident by another needs to be “paid back”.

Q: Could you say more about the obstacles to providing more generous parental leave policies at teaching hospitals?

Weinstein: A generation ago, residency programs had more flexibility. There was more elective time, the workload on inpatient rotations was less intensive, and administrative burden was not as heavy. Now there is less “give” in the system.

It is important to note that the coverage issues I mentioned vary across specialties and programs of different sizes. For example, a large internal medicine program with 100 or 150 residents will have an easier time plugging in substitutes when someone goes out on extended leave than, say, a small neurosurgery program with one resident per year. This would be true even if budget constraints weren’t a problem, simply because of the numbers. The larger internal medicine program could hire other trainees to moonlight or pick up extra shifts to help make sure patients were taken care of. Small programs often cannot do that — they just don’t have the people. So, often the work of a resident on leave is picked up by their co-residents, which can easily push them beyond duty hour limits.

Specialty board requirements are also an issue, as was highlighted by another study that appeared alongside ours in JAMA. Each board establishes its own rules regarding whether residents must make-up time spent on leave. If residents have 4 weeks of vacation a year, and then take parental leave on top of that, some (depending on specialty) may need to make up the time on leave before graduating. Delaying graduation from a residency program causes difficulty for trainees that are heading into a fellowship program, most of which start in July. Trainees can lose a whole year if they must wait to enter fellowship in the next academic year.

I hope that specialty boards will take a hard look at some of these issues. Allowing residents or fellows to graduate without making up time spent on leave — as long as they are competent for independent practice — is a logical approach that would represent an importance advance.

Q: Doesn’t this raise a whole different set of complications, allowing residents to graduate based on competency rather than time?

Weinstein: Yes and no. Indeed, determining when a resident is ready for unsupervised independent practice can be challenging and resident assessment is an area of active, ongoing research. But competency-based graduation (rather than time-based program completion) is being pursued widely in Canada and via a multi-institutional pediatrics pilot in the U.S. I think this will become standard in the future. If it does, one aspect of parental leave could become much simpler.

Q: Thinking about this current generation of residents, are younger doctors more adamant about the need for parental leave?

Weinstein: Residents today are just as dedicated to their patients and their education as residents were generations ago. However, the issues of well-being and work-life balance are appropriately under the spotlight and residents are feeling more comfortable in taking parental leave and advocating for benefits where they don’t exist. Many residents today aspire to have a reasonable work-life balance, and are thinking creatively about how to achieve that important goal. Ensuring access to paid parental leave seems essential to facilitate bonding with a new child, avoid excessive fatigue, support morale and hopefully reduce the risk of burnout.

Q: You mentioned some of the ways institutions are working to resolve these issues. Do you have any further recommendations in that regard?

Weinstein: Multipronged efforts are needed, including stronger policies that guarantee paid leave and continued cultural change so that taking parental leave isn’t seen as a stigma. Creating some redundancy in the system so that prolonged absences don’t cause coverage crises should also be a goal. Where redundancy isn’t possible, coverage should be guaranteed by the program without the new parent having to work out the details.

Happily, parental leave policies seem to be moving in the right direction. At the time our study was being conducted, policy revisions were underway at my own home institutions — Massachusetts General and Brigham and Women’s hospitals — and I’m delighted that we now provide 8 weeks of paid parental leave for all GME trainees, regardless of the parent’s gender, role in caregiving, or their specialty or level of training. More work is needed so that trainees everywhere can utilize parental leave as they tackle the lifelong work of balancing their personal and professional lives. —by Rob Volansky

For more information:
Debra Weinstein, MD, can be reached at 55 Fruit St, Bulfinch 230, Boston MA 02114; email: dweinstein@partners.org.

References:
Magudia D, et al. JAMA. 2018; doi:10.1001/jama.2018.14414.

Disclosures: Weinstein reports no relevant financial disclosures.

Debra Weinstein

Although pediatric medical organizations, including the American Academy of Pediatrics, have demanded congressional legislation to ensure that new parents receive 12 weeks of paid family leave — based on evidence of health benefits to the child — it appears that physicians are not following their own advice on the matter. According to recent JAMA findings, institution-wide policies providing paid family leave for residents were offered by only eight of 15 major medical institutions.

Debra Weinstein, MD, vice president of graduate medical education at Partners HealthCare and associate professor of medicine at Harvard Medical School, and colleagues, suggested that little information has been available on institution-level policies pertaining to paid family leave for residents. In the current study, the researchers reviewed 15 graduate medical education–sponsoring institutions affiliated with 12 medical schools.

The list of evaluated institutions mirrored a prior article that identified a cohort named to “top 10” lists based on research funding or academics. Weinstein and colleagues defined childbearing leave as absence taken by birth mothers; family leave as additional leave given to birth mothers, or to fathers or nonbirth parents with a new child; and maternity leave as encompassing both childbirth leave and designated family leave available to childbearing mothers.

 
Although pediatric medical organizations have demanded congressional legislation to ensure that new parents receive 12 weeks of paid family, many physicians are not following their own orders on the matter.
Source: Adobe

The researchers found that seven of the participating institutions provided a clear-cut policy on paid childbearing leave, with a mean duration of 5.7 weeks (range, 2-8 weeks). For maternity leave, the mean duration was 6.6 weeks (range, 2-10 weeks). In addition, seven institutions provided paid parental leave for nonbirth parents in their policies, with six of the seven including same-sex couples and adoptive parents, and one specifying “paternity” leave. Also among these seven institutions, 3.9 weeks (range, 1-8 weeks) of paid leave was reported.

Weinstein and colleagues noted that all 12 of the affiliated medical schools had policies providing paid parental leave for their faculty physicians. They added that the duration of paid leave for residents offered by all of the institutions was less than the 12 paid weeks currently endorsed by the American Academy of Pediatrics and the Pediatric Policy Council.

Healio Rheumatology spoke with Weinstein about the key findings of the study, the necessity of family leave at the societal level, and the dangers of over-working among health care professionals.

Q: Could you talk about the findings of your study?

Weinstein: We focused on parental leave policies currently in place for residents. Parenting during residency is particularly challenging. Residency training extends from 3 to as many as 7 years — often followed by subspecialty fellowship training. Residents and fellows work extremely long hours in very high stress jobs. They have often relocated for their training, and are geographically distant from their support systems. Many have significant educational debt: The average debt of graduating medical students is more than $180,000. So, as challenging as it is to be a new parent in any set of circumstances, it is particularly challenging for residents.

We were interested in looking at how different teaching hospitals handle parental leave. It is important to note that the Family Medical Leave Act, or FMLA, has provisions that allow up to 12 weeks of leave — but it doesn’t address salary continuation. We found that more than half of the institutions don’t have an institution-wide policy that guarantees paid leave.

We acknowledge that some hospitals without institution-level policies may be flexible and generous with policies or practices determined at the department or program level. However, there is a significant downside to this: it is hard for residents to make complicated family planning decision when they can’t identify a consistent leave policy and know in advance what they can count on. Also, residents should not have to disclose that they are considering having a child in order to get information about leave, and should not have to individually negotiate parental leave benefits.

Q: Could you offer some thoughts from the perspective of these institutions, whether they offer leave or not?

Weinstein: I believe that GME program leaders and teaching hospital executives are trying very hard to do the right thing and maximally support their trainees. But they face a variety of significant constraints — most notably the absolute imperative to ensure patient coverage in a context where teaching hospitals rely heavily on residents as caregivers. Residency programs have little redundancy with respect to patient care assignments, so resident absences are challenging.

Also, teaching hospitals usually face tight budget constraints — and covering absences with “moonlighters” or building intentional redundancy in staffing is expensive. There are also complicated issues to address in terms of fairness and/or equity among trainees, such as which activities need to be “made up” after a leave of absence, and whether coverage of one resident by another needs to be “paid back”.

PAGE BREAK

Q: Could you say more about the obstacles to providing more generous parental leave policies at teaching hospitals?

Weinstein: A generation ago, residency programs had more flexibility. There was more elective time, the workload on inpatient rotations was less intensive, and administrative burden was not as heavy. Now there is less “give” in the system.

It is important to note that the coverage issues I mentioned vary across specialties and programs of different sizes. For example, a large internal medicine program with 100 or 150 residents will have an easier time plugging in substitutes when someone goes out on extended leave than, say, a small neurosurgery program with one resident per year. This would be true even if budget constraints weren’t a problem, simply because of the numbers. The larger internal medicine program could hire other trainees to moonlight or pick up extra shifts to help make sure patients were taken care of. Small programs often cannot do that — they just don’t have the people. So, often the work of a resident on leave is picked up by their co-residents, which can easily push them beyond duty hour limits.

Specialty board requirements are also an issue, as was highlighted by another study that appeared alongside ours in JAMA. Each board establishes its own rules regarding whether residents must make-up time spent on leave. If residents have 4 weeks of vacation a year, and then take parental leave on top of that, some (depending on specialty) may need to make up the time on leave before graduating. Delaying graduation from a residency program causes difficulty for trainees that are heading into a fellowship program, most of which start in July. Trainees can lose a whole year if they must wait to enter fellowship in the next academic year.

I hope that specialty boards will take a hard look at some of these issues. Allowing residents or fellows to graduate without making up time spent on leave — as long as they are competent for independent practice — is a logical approach that would represent an importance advance.

Q: Doesn’t this raise a whole different set of complications, allowing residents to graduate based on competency rather than time?

Weinstein: Yes and no. Indeed, determining when a resident is ready for unsupervised independent practice can be challenging and resident assessment is an area of active, ongoing research. But competency-based graduation (rather than time-based program completion) is being pursued widely in Canada and via a multi-institutional pediatrics pilot in the U.S. I think this will become standard in the future. If it does, one aspect of parental leave could become much simpler.

Q: Thinking about this current generation of residents, are younger doctors more adamant about the need for parental leave?

Weinstein: Residents today are just as dedicated to their patients and their education as residents were generations ago. However, the issues of well-being and work-life balance are appropriately under the spotlight and residents are feeling more comfortable in taking parental leave and advocating for benefits where they don’t exist. Many residents today aspire to have a reasonable work-life balance, and are thinking creatively about how to achieve that important goal. Ensuring access to paid parental leave seems essential to facilitate bonding with a new child, avoid excessive fatigue, support morale and hopefully reduce the risk of burnout.

Q: You mentioned some of the ways institutions are working to resolve these issues. Do you have any further recommendations in that regard?

Weinstein: Multipronged efforts are needed, including stronger policies that guarantee paid leave and continued cultural change so that taking parental leave isn’t seen as a stigma. Creating some redundancy in the system so that prolonged absences don’t cause coverage crises should also be a goal. Where redundancy isn’t possible, coverage should be guaranteed by the program without the new parent having to work out the details.

Happily, parental leave policies seem to be moving in the right direction. At the time our study was being conducted, policy revisions were underway at my own home institutions — Massachusetts General and Brigham and Women’s hospitals — and I’m delighted that we now provide 8 weeks of paid parental leave for all GME trainees, regardless of the parent’s gender, role in caregiving, or their specialty or level of training. More work is needed so that trainees everywhere can utilize parental leave as they tackle the lifelong work of balancing their personal and professional lives. —by Rob Volansky

For more information:
Debra Weinstein, MD, can be reached at 55 Fruit St, Bulfinch 230, Boston MA 02114; email: dweinstein@partners.org.

References:
Magudia D, et al. JAMA. 2018; doi:10.1001/jama.2018.14414.

Disclosures: Weinstein reports no relevant financial disclosures.