Are Psychiatry Programs Providing Adequate Parental Leave to Their Residents?

OBJECTIVE: During residency training, parental leave is frequently briefer than may be optimal for the well-being of the family. The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to have a parental leave policy without providing specific guidelines on its makeup, resulting in varying policies and confusion among residents planning parental leave. This study identifies differences in parental leave policies in psychiatry residencies and discusses if these policies are adequate.
METHODS: A 45-question, anonymous survey was emailed to general psychiatry and fellowship program directors in the USA.
RESULTS: Out of 520 program directors contacted, 186 completed the survey (35.7% response rate). Among the respondents, 94.1% had policies for maternity leave, 79.8% had policies for paternity leave, and 67.2% had policies for non-childbearing parental leave (e.g., adoption). Variations were reported in implementation, coverage, and accommodations. Most respondents (57.1%) believed that residents would benefit from more parental leave. Some (11.5%) believed that parenthood negatively affected residents' overall performance, especially regarding patient care and clinical skills; 36.5% endorsed that parenthood negatively affected overall residents' well-being; and 7.5% felt negatively when an applicant was pregnant or was planning to become pregnant during residency. Lastly, 32.9% were not confident regarding ACGME, American Board of Psychiatry and Neurology, federal, and hospital policies.
CONCLUSIONS: Parental leave policies are not universal in US psychiatry residency and fellowship programs. Some program directors feel that parenthood adversely affects residents' clinical performance as well as well-being. If true, reformation of parental leave policies may be a remedy.

Although many studies indicate that the early bond between parents and infants is essential for positive developmental outcomes [1], in the USA, working parents are often required to return to work prematurely [2]. During residency training, parental leave is frequently brief due to pressure from residency programs including rotation requirements, on-call duties, and clinical work. In 2013, the American Academy of Pediatrics recommended residents be provided with at least 6–8 weeks of parental leave regardless of gender [3]. In 2019, most residents reportedly received an average of 6 weeks of paid parental leave, with some receiving less [4, 5]. Fathers and adoptive parents received the least paid leave, at an average of 3 weeks [4]. Furthermore, after returning from leave, residents reported negative bias when evaluated by peers and attendings [6, 7]. Studies have shown that program directors believe becoming a parent negatively affects female trainees’ work and increases burdens on fellow residents [8]. Program directors also perceived having children decreases well-being more often in female trainees than in male trainees [8].

The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to have a parental leave policy in place but has no specific guidelines on its makeup. In 2020, the American Board of Psychiatry and Neurology (ABPN) updated its leave of absence policy to include at least 6 weeks of parental leave without exhausting other leave time or extending training, but a similar policy has yet to be incorporated into ACGME guidelines, causing further confusion [9]. In one survey, program directors reported confusion about the rules presented for parental leave policies for residents [10]. Such lack of clarity results in institutions having varying policies and in applicant and resident confusion about options when planning parental leave [11].

Studies on the perspectives of surgical residency program directors about parental leave have occurred [8, 12, 13], but to our knowledge, none have studied the attitudes of psychiatry program directors toward parental leave. Traditionally, psychiatry is perceived as less physically challenging than surgery, but biases against parents, as well as lack of clarity about policies, may still be prevalent. The objectives of this study are to identify differences in parental leave policies among psychiatry residencies, assess whether accommodation is sufficient and within regulations, and suggest ways to improve current policies.

Methods

A 45-question, anonymous survey created on Qualtrics (Qualtrics, Provo, UT) was emailed to 520 general psychiatry and subspecialty fellowship program directors in the USA from August to October 2020. Email addresses were obtained from the Fellowship and Residency Electronic Interactive Database and the American Association of Directors of Psychiatric Residency Training membership database.

The survey received approval for exempt status from the HCA Healthcare Internal Review Board. Data analysis was conducted on Qualtrics. The survey was developed using similar questions to other studies regarding parental leave in residency programs [8, 12, 13] and piloted within one training program for any technical errors. The survey was subdivided into multiple sections, including leave policy, attitudes, and demographics.

Results

A total of 35.7% (186/520) of program directors responded to the survey. Among the respondents, 57.3% identified as female, 88.5% were parents, and 61.1% took personal parental leave during training.

Responses showed variations among parental leave policies (Table 1). Most programs (94.1%) had maternity leave policies, 79.8% had paternity leave, and 67.2% had non-childbearing parental leave policies. In the following questions, percentages equate to more than 100% as respondents were allowed to select more than one option. There were differences in access to parental leave policies, some found in a private site (24.3%), upon request (24.1%), publicly (19.4%), in the employment contract (16.5%), and/or in recruitment material (13.0%). Lastly, 4.5% of programs did not have parental leave policies available for review.

Table 1

Program directors’ demographics and differences in programs’ parental leave (N = 186)

Variables	n*	%
Directors’ gender
Male	63	40.1%
Female	90	57.3%
Directors’ role
General psychiatry program director	102	65.0%
Fellowship program director	47	29.9%
General psychiatry and fellowship program director	8	5.1%
Do you have current policies for residents in regard to maternity leave?
Yes	175	94.1%
No	11	5.9%
Do you have current policies for residents in regard to paternity leave?
Yes	146	79.8%
No	33	18.0%
Not sure	4	2.2%
Do you have current policies for residents in regard to non-childbearing parental leave (such as adoption leave)?
Yes	121	67.2%
No	44	24.4%
Not sure	15	8.3%
Are residents who take parental leave required to make up missed call shifts?
Yes, all shifts	25	14.4%
Yes, some shifts	48	27.7%
No	83	48.0%
Not sure	17	9.8%
If residents cover for co-residents, do residents receive additional financial compensation for coverage for night/weekend calls?
Yes	2	1.2%
No but night/weekend calls are reduced later	57	33.3%
No, residents cover without additional financial compensation or schedule rearrangement	67	39.2%
Not sure	9	5.3%
Residents do not cover for co-residents in my program	36	21.0%
Where can your parental leave policies be accessed? (Select all that apply**)
Publicly accessible online	67	19.4%
Available on a private site	84	24.3%
Included in employee’s contract	57	16.5%
Available upon request	83	24.1%
Included in recruitment materials provided at residency interviews	45	13.0%
They are not available	9	2.6%

*Because not all questions were answered by all participants, the denominator is different for each question

**Percentages equate to more than 100% as respondents were allowed to select more than one option

Notable differences existed regarding how leave time was allocated. For example, 90.8% of respondents gave the option of extending the residency, 53.7% of programs required use of sick or vacation time for parental leave, and 39.3% allowed residents to take short-term disability. Furthermore, variations existed in the way missed night calls were covered. Among respondents, 48.0% did not require residents taking parental leave to make up missed call shifts and 64.2% had other residents cover shifts, 38.8% had fellows cover, 18.9% did not need coverage, and 3.0% hired moonlighters. Moreover, only some programs offered accommodations after residents returned to work; for example, 30.3% of programs placed residents in a research/elective month, 27.4% gave the option of working part time, and 17.4% provided the option of a reduced clinical load. However, 30.3% offered no accommodations after residents returned to work from parental leave. Additionally, 94.2% offered accommodations for lactating residents, which varied in that 80.6% of programs offered a room for pumping breast milk, 67.2% offered refrigeration for breast milk, and 50.7% blocked time from duties for pumping breast milk. Only 20.5% of programs had in-house childcare available.

The questionnaire assessed how program directors evaluated residents once they became parents and if their evaluations differed in relation to gender. Among the responding program directors, 11.5% believed that parenthood positively affected residents’ overall performance in regard to patient care and clinical skills and negatively in scholarly activity and timeliness. Moreover, 72.6% of respondents did not think that there was a difference in overall performance between men and women taking parental leave; however, 20.1% thought that men’s performance was affected less negatively than the performance of women. Furthermore, 36.5% believed that parenthood negatively affected overall residents’ well-being, versus 46.0% who believed that parenthood positively affected overall residents’ well-being. This opinion did not differ by trainee gender. Lastly, 67.9% did not think that there was a difference in overall well-being between men and women taking parental leave; however, 21.0% thought that men were affected less negatively than women.

The best timing for leave was also assessed. Among the responding program directors, 38.8% considered any year to be reasonable to have children, 35.1% thought the fourth year of general training was the best due to increased elective time, and 13.3% believed leave is easier to coordinate during the third (outpatient) year.

A common theme in the comment section was that responding program directors were very supportive of residents taking parental leave. In fact, when adding the responses of those who answered that they strongly agree, agree, or somewhat strongly, 57.0% agreed that trainees could benefit from more parental leave time. Again, when adding those who agreed, 32.8% endorsed a lack of confidence in knowledge of ACGME, ABPN, hospital, and federal policies, and 25.9% reported a struggle to find service coverage when trainees take parental leave. Also, 28.5% stated that insufficient resources exist to provide appropriate parental leave. Lastly, 7.5% stated they are negatively influenced when applicants are pregnant or plan to become pregnant during residency (Table 2).

Table 2

Program director responses to statements regarding parental leave

Statements	Strongly disagree	Disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Agree	Strongly agree
I am negatively influenced when applicants are pregnant or plan to become pregnant during residency.	46.0%	26.7%	5.0%	14.9%	5.0%	2.5%	0.0%
There are insufficient resources to provide appropriate parental leave.	29.8%	18.0%	8.7%	14.9%	14.9%	10.6%	3.1%
I struggle to provide service coverage when my trainees take parental leave.	29.8%	23.0%	8.7%	12.4%	19.3%	5.0%	1.9%
My trainees could benefit from more parental leave than given.	3.7%	9.9%	3.1%	26.1%	13.7%	22.4%	21.1%
I am confident of the ACGME*, ABPN**, hospital, and federal policies when it comes to planning parental leave.	3.7%	16.1%	13.0%	15.5%	13.0%	26.1%	12.4%

*Accreditation Council for Graduate Medical Education

**American Board of Psychiatry and Neurology

Discussion

Parental leave policies are not uniform in psychiatry residency and fellowship programs in the USA and are variably disseminated. The lack of uniformity and transparency creates challenges for residents and applicants as they plan for parental leave. Residents may not be aware of their options if policies are not readily available, and medical students applying for residency training may feel uncertain about asking about such policies for fear of negative ramifications in the selection process. Previous surveys about parental leave indicate that confusion exists because of lack of standardization and open discussion [11].

Transparent policies for potential and existing residents would facilitate open conversations and help residents planning families. Mandatory regulations and detailed suggestions on how to organize parental leave would provide clarity and consistency. This survey confirmed that negative biases exist toward residents who take parental leave. Pressure to return to work prematurely or being in an environment with insufficient support could impact work performance and wellness. New parents may need to recover from pregnancy and delivery and adapt to a different sleep schedule and lifestyle. In one study, residents with greater than 8 weeks of parental leave were less likely to have postpartum depression or burnout and more likely to breastfeed longer, perceive support from colleagues and program directors, and be satisfied with parenthood, but only a few programs provided such leave [14].

Negative biases may not only exist in program directors but also in faculty and co-residents. In another study, surgical residents who took parental leave reported a lack of support from faculty and colleagues [15]. Negative bias may result in poor evaluations [6]. To our knowledge, no survey studies have evaluated co-residents’ and faculty members’ perspectives on parental leave. The culture of medicine has a history of considering time away from work in a negative light, however, and the need to increase workload to cover for an absent resident is likely to produce negative attitudes.

Our study has several limitations and survey biases. The response rate is lower than some previously published studies, with responses around 60.0% compared to this study’s 35.7% [8, 12, 13]. The survey was sent during the COVID-19 pandemic, which could have affected the response rate. Moreover, participation bias may have played a factor because program directors holding more negative biases about residents’ parental leave may have been less willing to respond. Social desirability bias may have been present as program directors might have answered in a way that is more favorable to themselves or their program. Despite these limitations, the responses identified gaps and disparities between programs and directors.

While some progress toward uniform standards of parental leave has been made by organizations such as ABPN, there is not yet a standard in psychiatry residencies for such an important time away from work. A universal parental leave policy available to all psychiatry program directors and residents would result in uniformity and fairness. A clearly delineated plan would resolve ambiguity, increase residents’ confidence about starting a family, and decrease potential biases. In addition, educating staff about the importance of parental leave may help alleviate biases between genders and about the leave itself.