Perspectives of General Surgery Program Directors on Paternity Leave During Surgical Training

This qualitative study evaluates attitudes and perceptions of US surgical program directors on leave for nonchildbearing or male surgical residents.

Key Points

Question

What is the perspective and experience of surgical program directors on paternity leave?

Findings

In this qualitative study of 40 surgical program directors, fear of stigma and limitations on board eligibility were found to be the main drivers of brief paternity leave despite a desire for longer leave.

Meaning

Development of defined leave policies at individual programs for a nonchildbearing parent is a step toward making parental leave socially acceptable among surgical residents.

Abstract

Importance

Although men are increasingly involved in childrearing, little is known about paternity leave in surgical residency. Conflict between professional and family duties contribute to burnout and decreased career satisfaction for surgeons of both sexes. With men more likely than women to have children during their clinical years of surgical training, understanding the issues surrounding paternity leave is imperative to ensuring the longevity of our workforce.

Objective

To explore surgical program directors’ perspectives on the challenges of providing paternity leave.

Design, Setting, and Participants

This qualitative descriptive study of transcripts collected from semistructured interviews of US surgical program directors was performed from October 2018 to June 2019. Program directors were selected using purposive-stratified criterion-based sampling. Interviews were audio-recorded and transcribed verbatim, with emergent themes identified using content analysis.

Exposure

Paternity leave.

Main Outcomes and Measures

Program directors’ perspectives on paternity leave were categorized into common themes.

Results

A total of 40 US general surgery program directors were interviewed (28 male [70%]; mean [SD] age, 49.7 [6.8] years; 36 [90%] were university-based programs). Twenty (50%) reported providing paternity leave of 1-week duration. Five major themes were identified: (1) paternity leave policies are poorly defined by many programs and require self-initiation by residents; (2) residents often do not take the full amount of time offered for leave; (3) stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave; (4) paternity leave has little to no impact on colleagues’ workload owing to the brevity of time taken; and (5) men desire longer leave than what they are currently offered and wish to receive equal time off compared with childbearing parents.

Conclusions and Relevance

Surgical program directors report male residents take brief paternity leave despite a desire for more time off, which may be influenced by fear of stigma and surgical culture that avoids handing off work, even for short periods of time. A cultural shift toward supporting family planning as a normal part of young adult life, rather than a medical condition to be accommodated, is necessary to promote life balance and behaviors that will sustain a long career in surgery. Implementation of defined leave policies at individual programs for the nonchildbearing parent is critical to make parental leave socially acceptable among surgical residents.

Introduction

Societal values and gender roles have evolved throughout the last several decades, with an increase in dual-career families,¹ an emphasis on egalitarian division of household responsibilities,² and greater expectation of paternal involvement in child rearing.^1,2 Four decades ago, married fathers spent a mean of 2.6 hours per week caring for their children, an amount of time that has now tripled.³ These generational changes have affected the surgical profession as well, with medical students deterred from the career by the perception of incompatibility with childrearing.⁴ Among working surgeons, the ability to integrate work and family commitments is an important mediator of burnout.⁵

As surgical residencies reach gender parity, the challenges of motherhood during training have received more attention, with recent studies describing the need for improved maternity leave policies, culture change to reduce stigma for pregnant residents, and improved support for lactation and childcare.^6,7,8 Yet, male residents are more likely to be married and to have children during training, explaining increasing interest in paternity leave policies.⁹ The benefits of paternity leave are well established, including increasing new parents’ duration of breastfeeding¹⁰ and nurturing high-quality father-child relationships,¹¹ but less than half of surgical program directors in the United States report a formal paternity leave policy.⁸

Little is known about the structural and cultural barriers to paternity leave in surgical residency. Program directors are leaders who cultivate an environment that encourages or discourages parental leave and also effectors who implement scheduling changes for involved residents. Understanding their perspectives is essential to fully analyze this complex issue. The aim of this study was to evaluate attitudes and perceptions of US surgical program directors on leave for nonchildbearing or male surgical residents. Barriers against implementation and adaptations to accommodate local training culture were explored to inform policy recommendations for surgical education leadership.

Methods

Study Design and Setting

A qualitative study design consisting of semistructured interviews with surgical program directors was used to explore perceptions of paternity leave and to identify potential barriers. This study was approved by the institutional review board at Brigham and Women’s Hospital.

Participants

Program directors from Accreditation Council for Graduate Medical Education–accredited US general surgery training programs were invited to participate via email, with reminders sent 2 weeks after the initial invitation. No incentive was offered. Purposive stratified criterion-based sampling was used to select participants from all geographic regions and from different program sizes. This sampling method emphasizes selection of participants based on their knowledge and experience with the event of interest, providing detailed and generalizable information across diverse training cultures.¹² Data on race and ethnicity were not collected because of the limited number of participants.

Interview Guide

An initial interview guide was developed using systematic literature review and expert opinion to identify major themes on paternity leave during training. Open-ended questions tailored to the program director role were established, narrowed to key questions, and iteratively revised. Fifteen questions were included in the final interview guide (eAppendix in the Supplement), focusing on the presence of defined leave policies, barriers for program directors against implementation of leave, perceived impact of leave on residents’ quality of work, and the challenges of providing mentorship for work-life integration.

Interview Procedures and Data Analysis

A 30-minute interview was conducted with program directors who agreed to participate from October 2018 to June 2019 by the primary investigator (M.C.-A.), who has advanced training in qualitative research. Verbal informed consent was obtained at the beginning of each interview, followed by a brief summary of the study objectives. The remaining time was used for the interview, which was audio-recorded and transcribed verbatim.

Two authors (M.C.-A. and E.L.R.) independently read and coded transcribed responses using standard techniques of directed qualitative content analysis.¹³ A preliminary coding scheme based on initial survey themes was revised in real time immediately following interviews and used to analyze new data using the constant comparative approach. This permitted new topics not included in the original interview guide to be explored as concepts emerged from the interviews. Revisions were applied to previously coded transcripts. Joint discussions were held at regular intervals to resolve discrepancies until 100% agreement was achieved. A finalized codebook was created and entered into Atlas.ti version 8 (Scientific Software Development) software. Content analysis was used to sort codes into emergent themes, with illustrative quotes classified within each theme. Responses were continuously reviewed until thematic saturation was reached, defined as the absence of new themes after 3 consecutive interviews.¹⁴ Sample characteristics were summarized using the mean and standard deviation for continuous variables and frequencies and percentages for categorical variables. Two-sided P values were statistically significant at .05. Analysis took place between December 2019 and February 2020.

Results

Of 264 Accreditation Council for Graduate Medical Education–accredited general surgery residency programs, 80 program directors were invited to participate. Forty program directors agreed to be interviewed, representing 15% of all Accreditation Council for Graduate Medical Education–accredited programs. Interviewees were mostly male (28 [70%]) with a mean (SD) age of 49 (6.80) years and had a mean (SD) of 7.65 (5.13) years’ experience as program director. Compared with the demographics of program directors nationally,¹⁵ the program directors who participated had similar gender distribution (12 [30%] vs 18.4%; P = .08) but more years of experience (mean, 7.65 vs 3.95 years; P < .001). Thirty-one program directors (77.5%) reported having at least 1 child, and 23 program directors (47%) reported that these children were born after completion of training (Table 1).

Table 1. Demographic Characteristics of Program Directors.

Characteristic	No. (%)
Sex
Male	28 (70)
Female	12 (30)
Marital status
Single	4 (10)
Spouse or partner	36 (90)
Employed	27 (75)
Unemployed	9 (25)
Divorced	0 (0)
Widowed	0 (0)
Children, mean (SD)
Yes	31 (77.5)
No	9 (22.5)
Children born by stage of training, mean (SD)
During medical school	2 (4.1)
During residency	13 (26.5)
During fellowship	11 (22.4)
As an attending physician	23 (47.0)
Time in practice, y	16.05 (7.11)
Time as a program director, y	7.65 (5.13)

Most participants (36 [90%]) were from academic centers and represented programs from all geographic regions of the country. These programs had a mean (SD) of 6.67 (2.16) chief residents and most (29 [72.5%]) had gender parity with 40% to 60% female residents. In most programs, residents with children represented a minority, with 34 program directors (85%) reporting less than 40% of their residents were parents (Table 2). Half of program directors (20 [50%]) reported male residents were given paternity leave of 1 week duration, with few reporting a 2-week leave.

Table 2. Residency Program Characteristics.

Characteristic	No. (%)
No. of chief residents, mean (SD)	6.67 (2.16)
Type of program
Independent	4 (10)
Academic	36 (90)
Geographic region
Midwest	11 (27.5)
Northeast	14 (35.0)
South	6 (15.0)
West	9 (22.5)
Female residents, %
0-20	0
21-40	10 (25.0)
41-60	29 (72.5)
61-80	1 (2.5)
81-100	0
Residents with children, %
0-20	16 (40.0)
21-40	18 (45.0)
41-60	3 (7.5)
61-80	3 (7.5)
81-100	0

Five major themes emerged: (1) paternity leave policies are poorly defined by many programs and require self-initiation by residents; (2) stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave; (3) residents frequently do not take the full time allotted for leave; (4) paternity leave has little to no impact on colleagues’ workload owing to the brevity of time taken; and (5) male residents desire longer paternity leave without extending training or using vacation time, with equity in time off compared with childbearing trainees. Table 3 includes illustrative quotations for each described theme.

Table 3. Representative Quotes for Each Theme.

Themes	Illustrative quotations
Paternity leave policies are poorly defined by many programs and require self-initiation by residents.	“We do not have a formal paternity policy in our institution; it’s just you can use it as part of your other types of leave.” “The residents are the ones who came in asking for more time and so we wrote our policy.” “There is a little bit of tension around just trying to find a schedule and set them up [for paternity leave].”
Residents frequently do not take the full time allotted for paternity leave.	“We have paternity leave, although our residents do not formally take advantage of paternity leave.” “Since we just started our 2-week [paternity leave] policy, we just had our first 2 residents go through the potential for 2 weeks off, and both of them only took about 5 days off.” “We allow fathers to take up to 2 weeks, [but] I have never had anybody do that.”
Stigma against paternity leave is common, and men may face more stigma than women taking parental leave.	“We still have some older faculty members who are, you know, ‘I went and saw my child born and then I went back to work 3 hours later.’” “I think that the faculty is much more judgmental of men taking the time than they are of women.” “I think that in particular many unmarried male residents are very critical of male residents who take paternity leave.” “They usually are coming back with the idea that I need to make this up to my fellow residents, so I think they usually will come back with the spirit of wanting to work harder.” “I think we have kind of a liberal culture in our place so a man would feel comfortable taking time off to be home with his new baby. I think it is supportive. But then if it turned into 6 weeks, I think I would have a different story in my hands.”
Paternity leave has minimal impact on colleagues’ workload owing to the brevity of time away.	“Paternity leave has no impact [on coresidents] really but only because the paternity leave is a short duration.” “There is no impact because it is basically a week of vacation.” On the impact of paternity leave: “[It is] certainly not to the extent of the pushback that you hear about female residents because paternity leave is a much shorter time; in fact some [faculty and residents] do not even know they are gone because it is only 1 or 2 weeks.” “Again, if male residents took a full 6 to 8 weeks, there probably would be an impact. But all just take an extra week or something and that has not been an issue.”
Male residents desire longer parental leave and equal time away compared with childbearing residents without extending training or taking from vacation.	“There has been talk of, should [paternity leave duration] be more… especially because we have had more fathers than mothers.” “It is not fair. Men should get extra weeks off just like women do; they should be able to do the 46 [weeks] in 52 [weeks].” “Men get the short end of the stick there. I think people definitely do not accept the concept of extended paternity leave the same way that they do maternity leave, which I think I don’t know, that is probably not fair.”

Poorly Defined Paternity Leave Policies

Although half of program directors (20 [50%]) provided paternity leave to their residents, most reported that their programs do not have explicit leave policies for new fathers. Instead, program directors described using other types of leave (ie, vacation, bereavement, or sick leave) to provide a mean of 1 week of time off for new fathers without impacting required training time. Some described male residents taking the initiative to establish a formal paternity leave policy in their institutions.

Greater Stigma Against Paternity Leave Than Against Maternity Leave

Despite the short duration of leave and minimal impact on the resident workflow, stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave. Program directors described faculty members who commented on the way surgical training and fatherhood were handled in the past, with many taking no paternity leave when their own children were born. Program directors believed stigma against taking time to bond with a new child was greater for men than for women, perhaps explaining why many took fewer days off than permitted. Several perceived there would be greater repercussions for male residents who decided to take a similar 6-week parental leave duration as their female counterparts, with negative reactions from colleagues and faculty. Yet, most program directors reported they were supportive of such equitable leave policies.

Many Residents Do Not Use Permitted Time Off for Paternity Leave

Program directors reported that male residents often did not take the full time allotted for paternity leave despite being offered 1 week (or sometimes 2 weeks) away. Several who had a formal paternity leave policy in their institutions reported their residents did not use it or took fewer days away than what the policy allowed.

Minimal Impact of Paternity Leave on the Workload of Peers

Program directors described little to no impact of paternity leave on colleagues’ workload owing to the brevity of time taken. In contrast to maternity leave, which typically includes at least 6 weeks of time away, paternity leave had minimal impact on the program and several program directors believed faculty often did not even realize the resident was away.

Desire for Longer Leave and Equity Among Childbearing and Nonchildbearing Parents

Program directors reported that male residents often expressed concerns and frustration about insufficient duration of paternity leave and perceived inequities in policies for childbearing and nonchildbearing residents. Some desired longer leave without extending training or using vacation time, similar to the medical leave previously provided to childbearing female residents by the American Board of Surgery. These interviews took place prior to the addition of the American Board of Surgery family leave policies in 2019, which now include 2 weeks off up to 2 times during training for nonchildbearing parents.¹⁶

Discussion

Despite growing interest in parental leave and reducing drivers of burnout, the challenges surrounding paternity leave in training have received little attention. Paternity leave has well-known benefits for the family unit, including reducing domestic stress, improving maternal mental health and postpartum recovery, and providing lasting benefit for father-child closeness and communication.^{10,17,18,19,20} In the surgical profession, perceptions of work-life conflict drive career dissatisfaction and burnout,⁵ which may be mitigated by paid time off for new parents. Authorities on pediatric health and medical education, including the American Academy of Pediatrics²¹ and the American Medical Association, have issued position statements advocating for written policies that provide at least 6 weeks of paid leave for trainees.²² Despite advocacy by national medical leadership, the current study shows defined paternity leave policies have not been implemented consistently across surgical programs. Many program directors provide time off in an ad hoc fashion, a practice that may lead to anxiety for the resident expecting a child and morale problems among residents asked to cover without advance planning.²³

Although written paternity leave policies are a first step in supporting new fathers, such practical interventions may be insufficient for paternity leave reform in surgical training. In this study, cultural challenges were evident in program director interviews, which describe faculty expectations that parenthood should be handled similarly to the past. Some of these surgeons recounted they had taken no time off after the birth of their own children and used this as a metric against which they compared the behavior of current male residents. Historically, surgeons avoided personal responsibilities that interfered with hospital work,²⁴ but adhering to these practices perpetuates unhealthy norms that do not reflect our organizational goals to promote physician wellness.

In contrast with expectant female residents who require time to recover from childbirth, leave for new fathers is not validated by a visible physical need but requires understanding of the less tangible importance of paternal involvement in childrearing. With mentorship and hierarchy being cornerstones of academic surgery,²⁵ male surgical residents may face greater pressure to conform to the traditional surgical training paradigms practiced by same-sex attending physicians. This creates a cultural barrier against new fathers taking time to bond with their children and represents a generational divide²⁵ that may be bridged through faculty education on modern domestic priorities.

In practice, cultural barriers manifest as male residents forgoing leave or taking less than the allowed time away. Similar to guilt precluding pregnant residents from requesting longer maternity leave,⁷ male residents are resistant to increasing clinical burden for their peers, with new fathers in training reporting that “good residents [are those who] take as little time as possible.”⁸ Despite perceptions by program directors that paternity leave is too brief to significantly strain coresidents, signing out patient care even for short periods violates the traditional professional identity of the surgical resident, negates the toughness implicit in forgoing time to bond with a new child, and is viewed as a burden by a significant proportion of trainees.⁹ Ethnographic studies of surgical residents during the 2003 work hour reform validate the complexity of enacting changes that challenge traditional training expectations, with junior residents extremely reluctant to hand off work to more senior residents in new night float models. Similar to the changes enacted to eliminate those hierarchy violations during duty hours reform,²⁴ new fathers may face less stigma and resentment if clinical coverage for missed work is provided by moonlighters or advance practice providers rather than other residents. Leadership must engage residents in creation of clinical coverage schemes for leave policies, paying careful attention to cultural barriers to navigate successful change.²⁴

This study demonstrates that men prioritize equitable leave. Before August 2019, the American Board of Surgery provided time off only for childbearing residents under a personal medical leave policy.⁹ Exclusion of nonchildbearing residents from these policies may have contributed to inconsistencies in the methods with which program directors provided them with short periods of time off to bond with a new infant, such as using sick leave or bereavement time off. Recent adaptation (American Board of Surgery family leave policy) now includes 2 weeks of parental leave for childbearing and nonchildbearing residents.¹⁶ This provides equity for all routes to parenthood, removes the implication that pregnancy is a medical exception to be accommodated, normalizes family bonding time, and offers program directors and residents a consistent way to provide leave without extending training. Despite these progressive changes, more work remains to be done. Effective July 2021, the American Board of Medical Specialties allows at least 6 weeks parental leave for all residents “without exhausting all other allowed time away from training and without extending training.”²⁶ To maintain some vacation time the year a child is anticipated, residents may need to borrow vacation from other clinical years, thereby shortening periods of clinical rest for new parents already at risk for burnout.^7,27 Faculty mentorship in navigating new domestic and career priorities may mitigate this risk.²⁸ Longer leave for male residents who currently take 1 to 2 weeks off presents logistic and workforce challenges that may disproportionately affect smaller programs with little redundancy. As the demand for parental leave grows, additional service-based advance practice providers may offset the workload of more junior residents,²⁹ allowing greater operative opportunities for remaining residents.

Unlike recent increases in program-level maternity leave policies, there has been little progress in paternity leave policies. As the importance of supporting pregnant residents has risen to the forefront of work-life integration discussions,^7,8,28,30,31 studies of surgical program directors suggest formal maternity leave policies have increased by as much as 50% from 2016 to 2019.^8,32 In contrast, the current report suggests paternity leave policies are no more prevalent than they were in 2016.^8,32 Perceptions that men face fewer challenges returning to work after having a child compared with female residents may result in less initiative to change the status quo for men. For example, although program directors described poorer clinical performance among certain childbearing female residents,³² in this study they did not perceive the same negative impact on new fathers. Compared with female residents, having children is believed to exert less negative influence on male residents’ well-being.⁸ Caution must be taken that literature endorsing continued work performance of new fathers does not assuage the need for policies that improve work-life integration. The impact of adequate infant bonding time on the well-being of male residents should not be underestimated because childbirth is a life-changing and emotional event for both parents. The current study found that program directors believe support for new fathers in training still falls short of what residents desire, consistent with national surveys demonstrating that 83% of male surgical residents believe paternity leave should be longer than 2 weeks.⁹ The long-term consequences of work schedules that conflict with desired family time are burnout and career dissatisfaction among both male and female surgeons.^5,33

Limitations

This study is limited by underrepresentation of community and military programs despite sampling methods designed to capture a diverse cohort. Future work to understand how paternity leave impacts training experiences in these programs will help define unique challenges, particularly for programs with fewer residents to cover service gaps. Nonetheless, many recommendations are relevant to all US programs because cultural barriers to leave and board eligibility requirements are similar nationally. Response bias may have resulted from program directors with greater interest in parental leave being more likely to participate in this study. However, the longer years of program director experience represented by our interviewed cohort substantiates their viewpoints from the context of a more robust knowledge of available leave options and a longitudinal perspective of the experience of new fathers in training. The current study was intentionally limited to viewpoints of program directors to understand the structural and cultural barriers to implementation of paternity leave, but additional studies are necessary to understand the perspectives of surgical trainees who may provide additional insight. Lastly, although paternity leave was explored in this study, we acknowledge this nomenclature is not inclusive of surgeons in same-sex relationships who may face unique challenges. Individual study of the parenting experiences of lesbian, gay, transgender, and queer surgeon trainees, including adoption and surrogacy, are needed to define the needs of all surgeons starting families.

Conclusions

The themes identified by this qualitative analysis of general surgery program directors demonstrate that paternity leave for residents is inconsistent, often improvised by the program director and remains shorter than what new fathers desire. The traditional surgical culture of putting work over personal life may disproportionately impact men compared with women. Pressure to adhere to this historic surgical identity may preclude male residents from taking the full leave permitted despite updated policies by the American Board of Surgery and American Board of Medical Specialties. A modern definition of a successful surgeon as one who integrates professional achievement with domestic fulfillment is important to reduce burnout and sustain our future workforce. As we reshape our surgical culture to embrace surgeons as parents, we should take advantage of an opportunity to improve our residency training system beyond what our specialty board requirements set forth. Our recommendations of methods to support contemporary desires of new fathers include creation of consistent paternity leave policies, education of faculty to bridge the generational divide, and reduction of stigma by reducing perceptions of hierarchy violations. These suggestions have the potential to stimulate recruitment and improve the morale of our current residents.

Supplement.

eAppendix. Interview guide