Introduction

Different opinions and perspectives on parental leave in the medical sector abound, alongside contradictory institutional guidelines concerning parental leave for residency programs. Given the demanding nature of medical residencies and their alignment with prime childbearing and child-rearing stages, institutions face increasing pressure to establish and elucidate parental leave policies. Over the past century, numerous countries have made substantial strides in guaranteeing paid maternity leave at the national level. Presently, the United States stands among only three countries globally that lack federal-level assurance of paid maternity leave.1 Despite women constituting nearly half of the U.S. workforce, merely 16% have the security of paid maternity leave through their employers. Consequently, many women return to work as soon as ten days after childbirth due to the financial pressures associated with unpaid leave.2 Despite mounting evidence indicating the health advantages for both mothers and children, paid maternity leave policies still need to be more consistently adopted in the United States.2

The rise in the number of women pursuing careers in the medical field is evident, as demonstrated by the fact that women comprised 47.9% of graduating medical students in 2019.3 This trend underscores the importance of examining the status of maternity leave policies within residency programs. Notably, there is considerable disparity in parental leave regulations among residency programs across various medical specialties. While historically male-dominated, many surgical subspecialties are witnessing an influx of female practitioners.4 However, orthopedic surgery lags in gender representation, with only 5.3% of orthopedic surgeons being female as of 2016.4 Consequently, maternity leave provisions for orthopedic surgery residents tend to be more stringent compared to other specialties.

The American Board of Orthopedic Surgery, responsible for accrediting orthopedic surgery residency programs in the U.S., stipulates that institutions can grant leave to residents per their respective policies, with residents expected to engage in a minimum of 46 weeks of full-time instruction annually.5 Notably, these regulations lack provisions for paid leave, and terms such as “maternity,” “paternity,” or “parental” are notably absent.5 Previous research has highlighted the significant stigma associated with taking parental leave in surgical residencies, which can adversely affect residents intending to utilize such leave.6–8 Therefore, it is imperative to investigate orthopedic residents’ family planning aspirations, familiarity with their institution’s leave policies, and perceptions of the stigma surrounding parental leave within their program.

This study aims to describe the current climate around parental leave during residency in orthopedic surgery programs from the resident’s perspective. This will be achieved by collecting residents’ understanding of the current parental leave policies available to them, the perceived atmosphere of their individual programs regarding parental leave, and the effect of family planning and parental leave on their surgical training.

Methods

Study design: A prospective cross-sectional survey was conducted to assess the perception of parental leave amongst orthopedic surgery residents enrolled in accredited orthopedic residency programs across the United States. Program coordinators and directors were contacted via e-mail to participate and to distribute the survey to their residents. Survey questions included general demographic survey, and questions specific to perceptions of parental leave largely adopted from several previously published surveys.9,10

Ethics: The study was approved by the Institutional Review Board (STUDY00006902).

Consent: Written informed consent was obtained for each respondent prior to completion of the survey electronically via RedCap, the data collection software utilized for survey dissemination and data collection.

Data Collection: Between March 20, 2023, and June 20, 2023, the finalized survey was disseminated via email invitation of an anonymous electronic survey built through Research Electronic Data Capture (REDCap) to all 210 US-based orthopedic residency programs as a single stage, cluster sampling through orthopedic Program Director and Program Coordinator contacts to disseminate to their residents; US-based orthopedic resident direct contact was unable to be obtained, as this information is not publicly accessible. Responses considered eligible for inclusion were those by current adult orthopedic surgery residents in US-based accredited programs. Survey responses were collected anonymously to ensure confidentiality and to promote candid responses. The survey contained 33 questions (Supplement 1) encompassing demographic information, marital status, parental status, residency information, familiarity with parental leave policies of both their home program and the ACGME/ABOS, expectation and perception surrounding the use of allotted leave time, opinions on parental leave impact, and family planning alterations due to parental leave policies.

Statistical analysis: Data were exported to SPSS version 29 (Mac version) for analysis. Descriptive statistics were calculated for all survey items, including frequencies, percentages, means, and standard deviations. Categorical data were analyzed using chi-square tests and numerical values with non-parametric Kruskal-Wallis test for numerical variables. Bonferroni adjustment was made for p-values provided for multiple comparisons. Overlapping topics also organized qualitative data. Null hypotheses were rejected if p values were less than 0.05. Those respondents who accessed the survey but did not provide answers to the complete questionnaire were excluded from final analysis.

Results

Of the 875 possible residency spots in United States based accredited orthopedic surgery residency programs, 81 potential respondents accessed the survey via the electronic link. 48 responded to the survey. The majority were male, representing 75% of the total sample, and ages ranged from 27 to 39, with a mean age of 30.7 ± 2.8 years. Regarding racial and ethnic representation, 89.6% identified as white/Caucasian, 4.2% as Asian/Pacific Islander, 4.2% as Multiple/Other, and 2.1% as Hispanic. Concerning professional status, the participants were distributed as follows: PGY1 (16.7%), PGY2 (14.6%), PGY3 (14.6%), PGY4 (27.1%), PGY5 (27.1%). Lastly, participants were associated with different training models, with 47.9% from university-owned, 39.6%% % from university-affiliated hospitals, and 12.5% from community-based programs.

Family planning: Marital status varied among participants, with 77.1% being married, 12.5% single but cohabitating with a significant other, 6.3% single never married, and 4.2% in a domestic partnership or civil union. At the time of survey administration, 77.5% of respondents reported having no children; 12.5% reported one child, and 8.8% reported two. 8 respondents had one child during residency training, and 7 had two. 62.5% reported that they had not had children during residency; of those who had children during training, 27.1% reported that they themselves had been pregnant, while 8.3% reported a child carried by their partner. Of these respondents, most (47.6%) reported taking 1-2 weeks off for leave for the birth of their last child; 14.3% reported less than a week for leave, and 28.5% reported taking between 3-8 weeks. A majority (54.2%) believe that less than four weeks is the optimal amount of parental leave during orthopedic surgery residency; however, 61.1% reported that they felt they had not taken enough parental leave for those children had during orthopedic surgical training. There was no difference between the parents with children and those without a child in their perception of the optimum time of for parental leave. However, male residents significantly felt the optimum allotted leave off should be 4 weeks (range 3-5), while the female respondents thought the parental leave period should be 5 weeks (range 5-6). 10.4% of respondents reported that they were currently expecting to have or adopt a child in the next 6 months at the time of survey administration. 59.1% of respondents reported that their spouse/partner was working full time. 60.4% reported some effect of training as altering their family planning.

Familiarity with parental leave policies: Almost half of respondents (44.2%) were not familiar with the Accreditation Council for Graduate Medical Education (ACGME) and ABOS’s policies regarding parental leave. 41.6 reported familiarity with their program’s policies. A literature review on comparisons of parental leave during residency yielded the results in Table 1.11–28

Table 1.Policies on parental leave
Organization/Specialty Policy on Parental Leave
ACGME 6 weeks of paid medical, parental, or caregiver leave at least once during an ACGME-accredited program with 100% of their salary for the first 6 weeks of this leave
ABMS Minimum of 6 weeks away once during training without exhausting vacation or extending training
ABOS (ortho) 46 weeks of orthopedic education per year, on average over 5 years, are required.
Organizations may provide individual leave and vacation times for the resident in accordance with overall institutional policy.
ABS (Surgery) 48 weeks of full-time clinical activity per year are required
May take additional 4 weeks off during the first 3 years of residency and 4 weeks off during the last 2 years of residency for documented leave.
ABP (Peds) 1 month of absence each year, including vacation, sick, or family leave.
Up to 8 weeks of additional medical or family leave if all training requirements are met.
ABFM (family med) Up to 8 weeks of family leave, and up to 4 weeks of other leave
ABOHNS (ENT) 6 weeks in any 1 year with the following exception: for one year during residency training, a resident can take parental, caregiver, or medical leave for up to six weeks with the balance of time up to a total of eight weeks (leaves plus vacation) used for vacation time
ABNS (neurosurgery) PDs should Follow HR policies of their institution when determining whether to approve leave requests
It is the PDs responsibility to ensure that residents who receive less than 84 months of training successfully complete the program, receive the full range of neurosurgical training, and can practice as safe neurosurgeons following residency
ABOG (OBGYN) Leave may be granted at discretion of PD with local institutional policy and applicable laws.
Total vacation + leave may not exceed 12 weeks in a single year of residency
No more than 24 weeks over the four years of residency
ABA (anesthesiology) Resident may be absent from training up to 60 working days during the years 1-3
ABA considers leave requests for up to 8 additional weeks
ABEM (EM) Additional 2 weeks for leave in instances where max of 6 weeks has already been reached
ABO (ophthalmology) Minimum of 6 weeks for leave without exhausting all other allowed time away from training and without extending training
ABIM (IM) 5 weeks per academic year for leave
Leave not used in one year can accumulate to be used in future years
ABPMR (PM&R) Additional 4 weeks away from training without using up vacation/sick leave
These additional 4 weeks may only be used once
ABPS (plastic surgery) 12 weeks of optional personal leave
ABPN (psych and neuro) minimum of 4 weeks of leave time (including vacation, sick time, parental leave) per year
Additional 6 weeks of time for parental/medical leave at least once during training
ABPath (pathology) Up to 6 weeks of leave without having to extend duration of training
ABR (radiology) Residents are eligible for certification if they don't miss more than 8 weeks per academic year
This represents maximal time off; residents that take more time than this off must extend their training
ABTS (thoracic surgery) Single 6-week leave of absence in addition to vacation time
ABU (urology) May provide leave in accordance with institutional policy
ABU requires 46 weeks of full-time activity per year, averaged over the first 3 years and the last 2 years

Perception of the stigma of parental leave and its effect: Despite a majority (52%) of participants reporting no discouragement from the program regarding taking full leave, most (62.5%) participants also reported that their program expected to take less than the full time allotted. A higher percentage of residents reported receiving some level of discouragement from taking the total amount of allowed parental leave from their co-residents (60.5%) compared to their residency program (47.9%). 85.4% report witnessing no discrimination against their co-residents who had taken parental leave regarding the procedures they were allowed to take part in before or after taking leave, and 94.1% of respondents reported no discrimination against themselves. Barriers identified in our survey included 17 respondents indicating understaffing, 12 respondents reporting concerns regarding missing out on education during leave, and 10 reporting guilt or pressure from peers or faculty.

Opinions on parental leave: 47.6% of those respondents who took parental leave during training reported a neutral impact; only 4.8% reported that they felt that taking parental leave had a negative impact on their own training. 37.5% of respondents reported experience with a coresident taking leave during their training, reporting a mean of 3.46±2.75 weeks taken by that co-resident. 38% of respondents viewed parental leave as having a positive impact on the resident taking leave, while 26% viewed the impact as unfavorable. However, when evaluating parental leave’s impact on the co-residents training of the resident taking leave, the responses shifted to only 15% positive and 42% negative. Most residents (62.5%) felt parental leave had a neutral impact on the program.

Discussion

In American workplaces, parental leave has seen an increase in prevalence over recent decades, yet there still needs to be more regulation and consistency concerning leave policies. Presently, the United States stands among only three countries globally that do not ensure paid family leave at the federal level.1 The most notable legislative stride in the U.S. regarding parental leave was the enactment of the Family and Medical Leave Act of 1993 (FMLA), providing covered employees with 12 weeks of unpaid leave. While this marked a significant advancement in family leave policy, it fell short of guaranteeing paid leave; strict eligibility criteria meant that only around 60% of workers were eligible for guaranteed unpaid leave upon its implementation.1

Parental leave policies across medical residency programs exhibit considerable diversity. Recognizing the demanding nature of medical residencies and the extensive work hours involved, physician organizations acknowledged the necessity of implementing parental leave provisions for residents. As early as 1989, The American College of Physicians (ACP) advocated for residency programs to adopt policies facilitating planned parental leave to support the well-being of residents.29 Remarkably, this recommendation preceded the enactment of the FMLA in 1993 by four years. Surgical residencies especially pose significant challenges to family planning during training. The demanding training hours and the complexities of juggling surgical education with childcare responsibilities necessitate careful consideration. Furthermore, emerging research underscores the heightened risk of pregnancy-related complications among surgical residents. A study conducted by Warnock et al. revealed that pregnant surgical residents encountered elevated rates of hypertension (17%), pre-eclampsia (17%), and miscarriage (11%).30 The desire to have children, coupled with the obstacles that surgical residencies pose regarding pregnancy and parenting, is posited as a contributing factor to the underrepresentation of women in most surgical subspecialties.30

Furthermore, despite a higher proportion of men in surgical residencies and more men becoming parents than women during their resident years, the utilization of paternity leave remains infrequent. According to a survey conducted among surgical residency program directors (PDs), 50% of PDs reported offering paternity leave durations of only one week.8 This study suggests that male surgical residents are reluctant to take paternity leave due to concerns about facing stigma from their peers and the prevailing emphasis within surgical culture on not delegating work to others.8 Our survey findings corroborate this observation; the majority of respondents reported taking only 1-2 weeks of parental leave; however, most also indicated that they felt this was insufficient. Most respondents of our survey indicated some level of discouragement from co-residents regarding taking the full extent of available leave. While our data does not suggest a perception of significant impact on the residency program, it does indicate a more negative perception of impact among co-residents. These results imply that residents may believe their co-residents hold the highest expectations regarding taking the entirety of their available leave.

The American Board of Orthopaedic Surgery (ABOS), a constituent of the American Board of Medical Specialties (ABMS), establishes the training criteria for orthopedic surgery residents. According to ABOS’s official policy, accredited programs mandate 46 weeks of orthopedic education annually, averaged over five years.5 Consequently, residents are allowed up to 6 weeks of parental leave per year, although there is no mandate for this leave to be compensated. In contrast, other specialties offer policies with more explicit provisions for a single parental leave period during the residency program (Table 1). The ABOS guidelines further specify that each program has the discretion to establish individual leave and vacation periods for residents “by overall institutional policy.” Consequently, respective institutions predominantly determine the duration and nature of leave as paid or unpaid. The results of our study reflect the ambiguity of policy governing orthopedic surgery resident parental leave, finding that less than half of our respondents are familiar with the parental leave policies that are available to them.

In recent years, there has been a trend towards more generous parental leave guidelines within organizations overseeing medical training. In 2020, the American Board of Medical Specialties (ABMS) mandated that all ABMS member boards offer six weeks of medical or parental leave without requiring residents to use their vacation time.12 This directive emphasized the need for residency programs to establish clearly defined leave policies, ensuring a minimum of six weeks of leave, but failed to specify whether this leave must be paid. In 2022, The Accreditation Council for Graduate Medical Education (ACGME) introduced a new policy requiring member organizations to provide residents with at least six weeks of paid parental leave, with compensation equivalent to or greater than 100% of their regular salary.11 This policy stated that organizations failing to comply with the new guidelines would face penalties starting July 2023. However, these have yet to be implemented, and there continues to be significant variation in parental leave policies among residency programs.

The failure to implement updated guidelines may hinder the progress of diversity within the field, particularly impacting women and residents who become parents. This issue has implications for application rates, as evidenced by the 2023 cycle, where orthopedic surgery remains the least diverse specialty, with females comprising only 18.3% of applicants.31 Obstetrics and Gynecology, primarily a female-dominated surgical subspecialty, permits up to 12 weeks of combined vacation and parental leave within a single residency year, as outlined by guidelines from ABOG. In contrast, the ABOS specifies a maximum of six weeks for similar leave periods within a year.

Despite institutional policies, residents may opt not to utilize parental, medical, or caregiver leave, even if they are eligible. A significant reason for this reluctance among many women is the stigma associated with taking parental leave, coupled with a perception of being resented by co-residents, often leading them to either forgo maternity leave altogether or opt for a shorter duration than allowed.7 According to a study by Castillo-Angeles et al., which involved interviews with program directors of surgical residency programs regarding barriers to maternity leave, some of the most commonly identified reasons for residents not availing themselves of maternity leave included a reluctance to extend training due to missing required time, concerns about a potential negative impact on the quality of work, resentment from co-residents, and financial constraints.7 Among our cohort, the majority of respondents reported taking significantly less than the allowed time for parental leave, and the majority reported that less than 4 weeks would be ideal, even as the majority of respondents also reported that they felt they had not taken enough leave. This discrepancy highlights the result of the continued stigma surrounding parental leave.

Limitations: Limitations of this study include the power of our survey results. Our methodology was limited in that orthopedic residents could not be contacted directly, and sample size limited by our response rate, which was low; as this was a largely descriptive analysis, and given this limitation, power analysis was not included as part of this study. Our results demonstrate an initial query into the perception of parental leave by orthopedic surgery residents, outlining some preliminary trends, but our analysis did not reach data saturation. Our nonrespondent rate was also high, with 81 respondents initially accessing our electronic survey, but only 48 consenting to and participating in the survey questionnaire. Of the 33 who chose not to respond to our survey, we did not collect data as to the rationale for nonresponse. As a result, there is a risk of sampling and attrition bias. Our findings therefore cannot be generalized to the overall orthopedic surgery resident perspective of parental leave; however, there remains value in highlighting our limited analysis within the context of the diverse and evolving landscape of parental leave policy highlighted by our discussion. Future studies should aim to add power to the findings of this study, and to include the actual utilization of parental leave of orthopedic residents among analysis of the perceptions of leave highlighted by this survey.

Conclusion

As indicated in the preliminary results of our study, improved communication regarding the allocated time and anticipated involvement from departments in supporting the utilization of leave is essential. One obstacle reported by orthopedic residents was a reluctance to take parental leave due to concerns about burdening their co-residents. National governing bodies including the ABOS and AAOS play a pivotal role in ongoing efforts to standardize the parental leave allotted for orthopedic surgery residents; however, exploration of the stigma surrounding parental leave at the level of residency programs requires further study to fully understand and address it.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interest

No conflicts of interest are reported by any of the contributing authors to this study.