Achieving a satisfactory work-life balance during surgical training is challenging.1,2 One source of stress is how residency programs approach family leave for residents. Family leave, distinct from medical leave, is an excused absence from work to tend to a significant family event or seriously ill close family member. Surgical residency programs vary in their approach to policies regarding leave during training, as evidenced by the treatment of pregnancy and parenthood. One study found that just two-thirds of programs surveyed had a maternity leave policy, while less than half had a family leave policy for the non-childbearing parent.3 Even among programs with leave policies, there was wide variation in how they were implemented.3 The burden of administering leave policies is the purview of the individual training program or institution and its leadership, yet the constraints on what programs can offer are established by the certifying body.
The American Board of Surgery (ABS) allows a resident to have 4 nonclinical weeks per year of training (vacation, travel to conferences, interviews, and other absences), and an additional 2 weeks per year can be taken as “medical leave,” which encompasses personal illness and childbirth. Beyond this, any nonclinical time taken necessitates the lengthening of training. Under these guidelines, childbearing parents qualify for the 2-week “medical leave,” while non-childbearing parents are excluded. No provision is made for “family leave,” such as caring for a seriously ill family member or a new child. The only mention of family leave in the ABS policy is to specifically exclude it from medical leave, stating it can only be used for “conditions that directly affect the individual (ie, not family leave)” [emphasis from citation].4 This exclusion affects mothers who adopt, nontraditional families, and fathers.
The ABS is responsible for upholding standards of excellence in surgery, including defining eligibility for its certification examination. The organization has made a number of strides forward in recent years to accommodate trainees with specific circumstances during residency, including allowing for a sixth year of training, and providing 2 weeks of medical leave. The authors do not advocate for decreasing the duration of training. At the same time, we believe the 2 weeks of medical leave should be redefined to include a broader, widely accepted notion of family leave that conforms to societal norms and trainee expectations.5 Such a policy would give programs and sponsoring institutions the ability to administer leave based on local employment policies and accepted practices established by the Family and Medical Leave Act of 1993.5 Families and social norms are changing. The field of surgery needs to change with it. Long residency programs mean many trainee families cannot defer starting a family until after training and the absence of a gender-neutral family leave policy prevents programs from adapting to the present.
While this issue affects all surgical residents with families, we would be remiss if we did not discuss the impact family leave has on gender equality. There is a bias against starting a family during residency, particularly for female surgical residents. In a nationwide study of surgery program directors, 61% reported that becoming a parent negatively affected female trainees' work (as compared to 34% for male trainees). Program directors further reported that female trainees' well-being was negatively affected by a factor of more than 3 to 1 in comparison to their male colleagues.3 This could be a reason why female surgeons are less likely to have children than their male counterparts, and those who do are more likely to have their first child after completing training.1 Regarding sex discrimination in the military, Supreme Court Justice William Brennan stated that policies that affect only 1 gender “in practical effect, put women, not on a pedestal, but in a cage.”6 By restricting access to family leave to only 1 gender, these policies may exacerbate gender inequality by creating a difference where there need not be one.
In many ways, the barriers to parenthood during residency reflect a cultural phenomenon in surgery. Why is leave following the birth of a child only recognized in the form of “medical leave”? The ABS policy as it exists today does not adequately address the needs of current surgical trainees. When “life” happens to a surgical family, be it an emergency suffered by a loved one, or welcoming a new child, trainees should be able to take care of their families in a reasonable timeframe without jeopardizing their eligibility for certification.
Attrition from general surgery training programs is consistently higher when compared to other specialties. “Lifestyle” frequently is cited by residents as a major reason for leaving.7–9 The difficulty of balancing home and work obligations is not merely an individual-level problem; it also represents a challenge for the specialty. A step in the right direction is to establish a family leave policy, as described above, for all residents. This type of gender-neutral family leave would recognize adoptive families, nontraditional families, and promote gender equality in surgical training. It would acknowledge that the surgical community aims to do the right thing not only for patients, but also for each other and our families. To achieve a satisfying career, one's professional and personal lives must coexist symbiotically. Sensible family leave policies will set the stage for this balance to start in residency.
