What Proportion of Orthopaedic Surgery Residency Programs Have Accessible Parental Leave Policies, and How Generous are They?

Abstract

Background

Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that “the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants.” To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed.

Question/purposes

(1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed?

Methods

All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program’s website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected.

Results

Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution’s GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave.

Conclusions

Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program’s website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training.

Clinical Relevance

Parental leave policies are increasingly relevant to today’s trainees [18]. Applicants to orthopaedic surgery today value work/life balance including protected parental leave [16].

Introduction

Parental leave during graduate medical education (GME) is a component of physician well-being in the workplace. Both men and women in medical training face particular challenges given that residency and fellowship training often coincide with traditional childbearing years. The Accreditation Council for Graduate Medical Education (ACGME) does not have a single, defined parental leave policy that all GME programs must follow (Table 1) [2-5, 7, 19]. Although every GME program is required to have a leave policy, individual programs can create their own. The ACGME requires that every program provide parental leave policies to residency applicants [2].

Table 1.

Summary of policies of governing agencies that impact the length of leave taken by orthopaedic residents

Orthopaedic surgery as a specialty continues to work to overcome stereotypes to be an attractive specialty both to men and women. Perceived difficulties with, or negative attitudes towards, childbearing during training may deter applicants from pursuing orthopaedic surgery. The most common reason cited by women medical students for not choosing orthopaedics was the “inability to have a good work/life balance” [16]. Attention to leave policies is a component of having a specialty that is attractive to all applicants. Ninety percent of pediatric residencies, 88% of radiology residencies, and 67% of general surgery programs have a written, transparent parental leave policy [12, 13, 17]. Obstetrics and gynecology has had a national resident parental leave policy since 2016 [9]. A comprehensive review of leave policies in orthopaedic residency programs has not previously been reported. To our knowledge, the most pertinent manuscript reporting on this topic was an orthopaedic surgery program director survey in which only 31% of orthopaedic residency programs responded [20]. Because of this deficiency, the present study was designed to evaluate every orthopaedic surgery training program by review of website or direct contact with the program.

We asked: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed?

Materials and Methods

We identified all ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified [1]. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs comprised the study sample [6]. Two reviewers (BRS, JCF) examined each program’s website; one orthopaedic resident (BRS) and one orthopaedic-bound medical student (JCF). Intra-rater reliability was 86%. All discrepancies (24%, 23 of 166) between the two reviewers were resolved by a discussion until consensus was achieved. Discrepancies occurred when one reviewer found an aspect of the policy another had overlooked. The results were further validated by contacting 10% (17 of 166) of the programs and verifying the accuracy of the information. Eight of 17 of programs responded to data verification inquiries. There were only minor changes in policies found in the verification process with program coordinators. Data were collected over 10 months, from May 2017 to March 2018.

We conducted our search sequentially, starting with the residency program’s website. If no parental leave information was found on the residency program’s website, the institutional GME website was searched. If no parental leave information was available on either website, we initiated direct communication with the program via telephone and email. Two emails were sent and at least two phone calls made to programs without web-based information. This methodology attempted to replicate the approach of residency applicants seeking information. 9% (15 of 166) if programs had no web-based information nor was a response obtained after multiple email and phone communication attempts with the program coordinator. These programs were deemed to have “no written policy available to applicants” as mandated by the ACGME. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided generic sick leave pay, or deferred to unpaid Family Medical Leave Act policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected as available.

Statistical Analysis

Descriptive statistics were used. Data were stored and analyzed using Microsoft Excel® (Microsoft Corp, Redmond, WA, USA).

Results

Proportion of Orthopaedic Residencies with Parental Leave Policies

In all, 84% of programs had transparent, accessible parental leave information on their websites: 3% (5 of 166) on their program website and 81% (134 of 166) on the institution’s GME website. Sixteen percent (27 of 166) of programs had neither a program nor institutional policy available via a website. Direct communication with program coordinators confirmed written parental leave policies for another 7% (12 of 166) of programs. After both website review and direct communication, 9% (15 of 166) of programs could not be reached and were deemed to not have a written policy available to applicants (Fig. 1).

Fig. 1.

The methodology for obtaining leave policy information on ACGME-accredited orthopaedic surgery residency programs is shown here.

Parameters of Parental Leave Policies in Orthopaedic Residencies

In terms of compensation, a total of 21% (35 of 166) of programs offered paid parental leave. Twenty-nine percent (48 of 166) compensated parental leave through sick pay, and 50% (83 of 166) programs deferred to the FMLA (unpaid) leave (Table 2). Regarding length of leave, GME websites almost uniformly referenced the FMLA, stating that up to 12 weeks of leave could be taken, otherwise, most websites did not state the specific length of allowed parental leave. Five orthopaedic surgery programs that have program-specific parental leave policies on their websites and are presented as examples of best practices (Table 3).

Table 2.

Source of compensation for leave policies of ACGME-accredited orthopaedic surgery residency programs

Table 3.

Parental leave policies available on the orthopaedic residency website at the time of search

Discussion

Parental leave during residency training is important for work-life balance, and providing it is required under federal law in the United States. The most common reason cited by women medical students who do not choose orthopaedic surgery is the “inability to have a good work/life balance [16]. Most other specialties have easily accessible, written, transparent parental leave policies [9, 12, 13, 17]; the degree to which this is true has not been well explored in orthopaedic surgery. We found that although most orthopaedic surgery residency programs have a written policy, finding these policies was difficult; in fact, 15 programs did not have a written policy and failed to meet the ACGME requirement of providing parental leave policy for prospective residents. In addition, the terms of the leave policies were difficult or impossible to find online, and half of the programs (83 of 166) did not provide paid parental leave. Most programs simply deferred to the federal requirement of up to 12 weeks.

This study had several limitations. First, the information available on the website may not reflect the active leave policies available to residents. To account for this possible discrepancy, we identified a 10% subset of programs, and we contacted those residency coordinators by phone or email. We confirmed 53% of policies; 47% of programs did not respond. The second limitation is that this study did not evaluate whether information on parental leave policies plays a role in the decision making of a medical student, so the importance of this information is speculative. Further investigation would be needed to understand whether lack of clarity in parental leave programs effects enrollment of women in orthopaedic surgery or whether it effects physician burnout. Lastly, program policies and website content may be mandated by the institutional GME division, and may not be under the control of the residency program.

The first aim of our study was to assess availability of parental leave information for prospective orthopaedic surgery residents. We found that 91% (151 of 166) of programs have a written parental leave policy. This is a similar result as was seen in a 2016 survey of orthopaedic surgery program directors, which found 89% (40 of 45) of programs had a leave policy [20]. However, this study also reports that applicants to orthopaedic surgery with an interest in starting a family during training will find information regarding parental leave policies challenging to locate. Written, transparent parental leave information on the residency program webpage was present for only 3% (five of 166) residency programs. Eighty-one percent of orthopaedic surgery programs deferred to a general GME webpage for the institution, which was often difficult to navigate. Although leave information could often be found with great dedication, locating the information often took more than 15 minutes per program, and the policy was often vague. Although this study investigated whether parental leave policies were accessible, whether residents use those policies is a further question that was investigated in 2016 by Weiss et al. [20]. The authors found that 61% of programs reported no use of parental leave in their program and that only 3% of programs reported the use of paternity leave. Having a policy does not necessarily mean a resident will feel comfortable using leave time. Providing a work environment that is family-friendly may be important to diversifying the orthopaedic surgery workforce. A 2018 survey of women general surgeons who had a pregnancy during training found 39% strongly considered leaving surgical residency, and 30% of respondents reported they would discourage women medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training [15]. Pediatric residents stated parental leave policies were an important factor in selecting a residency program [8]. Surveyed women surgical residents were more than twice as likely as men to say family leave was very important (78% versus 32%) [14]. Despite the paucity of data on applicant attitudes, it is not unreasonable to assume that clear family-friendly leave policies would remove one of the barriers that may preferentially dissuade diverse applicants. Orthopaedic surgery does not appear to lag behind other specialties in terms of the existence of formal policies. In this study, 9% of orthopaedic surgery programs do not meet the ACGME requirement of having a written policy available to applicants. A survey of women urologists found only 42% reported a formal maternity leave policy [11]. Only 67% of general surgeons report having a formal maternity leave policy and 48% a paternity leave policy [17]. Larger general surgery residencies were far more likely to have a leave policy than small programs (less than four residents per year) [17]. A resident survey across specialties found only 50% of women residents were covered by formal maternity leave policies [10]. Ninety percent of pediatric residencies and 88% of radiology residencies have a formal parental leave policy [12, 13] and the American College of Obstetricians and Gynecologists has had a national policy statement regarding parental leave since 2016 [9]. Improvement in frequency and availability of written parental policies is occurring across specialties.

The second aim of our study was to understand what provisions are made for trainees in programs with a formal leave policy. In our study, 21% of programs offered paid leave, 29% provided sick leave, and 50% offered unpaid leave. Formal parental leave policies exist to fill the ACGME requirement but do not provide quantitative data on how much leave can be taken, if time in training will need to be made up, or how much income will be lost while on leave. In contrast, a 2016 survey of orthopaedic program directors (with a 31% response rate) found all programs fully paid resident leave time whether with dedicated leave pay, vacation, sick leave, or conference time [20]. Almost every institutional GME website referenced the FMLA which allows up to 12 weeks of leave but gives little useful information about what parental leave might actually look like to an orthopaedic surgery trainee. The authors are unaware of any orthopaedic surgery resident taking a 12-week maternity, paternity, or adoption leave, particularly in light of previous American Board of Orthopaedic Surgery (ABOS) requirements limiting annual leave time to 6 weeks per year. Recent changes in ABOS requirements allow annual leave time to 6 weeks per year, averaged over 5 years [5].

Conclusions

The ACGME requires that “the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants” [2]. Although we found that 91% (151 of 166) of programs met this requirement, current parental leave policies in orthopaedic surgery exist but are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Important improvements would be gained if every orthopaedic residency program clearly outlined parental leave policy on their residency program website, including compensation and length of leave. If the program defers to their GME policy, a direct link to the institutional parental leave policy, as well as verbiage regarding how that is applied in their program, would be recommended (Table 1). Substantial changes in parental leave policy may also now be possible, due to changes in ABOS policy. Orthopaedic residency training is highly regulated by the ABOS, which now allows up to 6 weeks of leave per year, averaged over 5 years, for trainees to sit for the part 1 board exam [5]. Research on the effect of clear parental leave policies with well-defined compensation and length of leave for both men and women in residency training, regarding subsequent attraction of orthopaedic surgery as a career choice, as well as for physician wellness, will need to be investigated in the future.